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CLINICAL    METHODS 

A  GUIDE  TO  THE  PRACTICAL  STUDY  OF  MEDICINE 


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BACTERIA   (pp.  523-532). 
(After  an  Original  Drawing  by  Richard  Midr.) 

«,  Bacillus   diphtheria;.     Long  forms.      24  hours'  growth;    agar    cult;    .stained 

watery  methyl  blue  ;   x  1,000. 
ft',  The  same  after  5  days'  growth.     Involuted  forms. 

b,  Bacillus    tubercle  in   sputum,    from   case   of    phthisis,     Stained    Z.   Neelsen  ; 

X  1,000. 

c,  Spirillum  cholera?.     24  hours'  growth  ;  agar  cult ;  stained  fuchsine  ;   x  1,000. 

d,  Pneumococcus  (Fraenkel's)  in  sputum,  from  case  of  acute  pneumonia.     Stained 

Z.  Neelsen,  fuchsine  ;  decolorised  in  weak  acetic  acid  ;   x  1,000. 
c,  Gonococci  in  gonorrhosal  pus.     Stained  thionine  blue  ;   x  1,000. 

[Byoutispiecc. 


CLWICAL  METHODS 


A    GUIDE    TO    THE    PKACTICAL    STUDY 
OF    MEDICINE 


BY 


EOBEET    HUTCHISON,    M.D.,   M.R.C.P. 

DEJIONSTRATOR   IN   PHYSIOLOGY,  LONDON   HOSPITAL  MEDICAL    COLLEGE 


AND 

HAEEY   EAINY,   M.A.,  F.KC.P.EcL,  F.R.S.E. 

UNIVERSITY   TUTOR   IN   CLINICAL   MEDICINE,    ROYAL   INFIRMARY,    EDINBURGH 


WITH     137    ILLUSTRATIONS    AND    8    COLOURED    PLATES 


PHILADELPHIA 

LEA      BUOTHERS     &     CO. 


1- 


LjC 


H^7 


PEEFACE 


The  title  "  Clinical  Methods "  probably  describes 
the  scope  of  this  book  better  than  any  other.  It  is 
not  intended  as  a  treatise  upon  medical  diagnosis. 
On  that  subject  there  is  already  a  sufficiency  of  good 
works  in  existence.  It  aims  rather  at  describing 
those  methods  of  clinical  investigation  by  the  proper 
application  of  which  a  correct  diagnosis  can  alone  be 
arrived  at.  To  every  student  when  he  first  begins 
work  in  a  medical  ward  the  question  presents  itself  : 
How  shall  I  investigate  this  case  ?  To  that  question 
the  present  work  is  intended  to  provide  an  answer. 
The  first  chapter  deals,  therefore,  with  the  methods 
of  case-taking  in  general,  and  includes  a  general 
scheme  for  the  investigation  of  medical  cases.  The 
rest  of  the  book  is  really  an  expansion  of  that  scheme, 
each  system  being  taken  up  separately,  and  the 
methods  of  investigating  it  described  in  detail. 

A  special  chapter  has  been  devoted  to  the  clinical 
methods  of  examining  children,  as  these  differ  in 
many  respects  from  those  employed  in  the  case  of 
adults.  Chapters  have  also  been  added  on  the  ex- 
amination of  Pathological  Fluids  and  on  Clinical 
Bacteriology,  subjects  which  are  daily  growing  in 
importance.  The  methods  employed  in  the  investiga- 
tion of  surgical,  gynaecological^  or  obstetric  cases  do 
not  fall  within  the  scope  of  the  work. 

No  efibrt  has  been  spared  to  make  the  book 
thoroughly  up-to-date,  and  it  is  hoped,  therefore,  that 
it  will  be  found  useful  by  those  practitioners  who  may 
wish  to  make  themselves  acquainted  with  the  latest 
methods  of  clinical  investigation.     While  the  whole 


vi  Clinical   Methods. 

book  has  passed  through  the  hands  of  both  of  us,  yet 
each  has  made  himself  specially  responsible  for  cer- 
tain parts.  Thus  Dr.  Rainy  has  written  Chapters 
II.,  IV.,  YI.,  and  XIV.,  the  sections  on  the  electrical 
examination  of  muscles  and  nerves,  on  the  parasites 
of  the  alimentary  tract,  and  on  the  microscopal  ex- 
amination of  the  urine.  The  rest  of  the  work  is  from 
the  pen  of  Dr.  Hutchison. 

In  order  to  avoid  burdening  the  text,  but  few 
references  have  been  given  to  authorities  and  original 
sources.  We  should  like,  however,  to  take  this 
opportunity  of  acknowledging  the  help  which  we  have 
received  from  various  friends.  Amongst  these  are 
Drs.  Alex.  Bruce,  R.  W.  Philip,  G.  Lovell  Gulland, 
and  John  Thomson,  who  have  helped  us  with  criticism 
and  advice  in  the  preparation  of  Chapters  IV.  and 
IX.,  VI.,  V.  and  XII.  respectively.  We  have  also 
to  thank  Dr.  Patrick  Manson,  Dr.  Byrom  Bramwell, 
and  Prof.  Symington  for  the  use  of  specimens  and 
illustrations,  and  Drs.  T.  F.  Milroy  and  J.  Purves 
Stewart  for  assistance  in  the  revision  of  proofs.  To 
Dr.  R.  J.  M.  Buchanan  we  are  specially  indebted  for 
jDreparing  the  drawings  illustrating  the  microscopical 
examination  of  the  blood. 

R.  H. 

H.  R. 

September,  1897. 


OOXTEXTS 


CHAPTER    I. 
Case-taking ^ 

CHAPTER    II. 
General  Condition  and  Appearances  ....       16 

CHAPTER    III. 
Alimentary  System  and  Abdomen         ....       42 

CHAPTER    IV. 
Circulatory  System ^' 

CHAPTER    Y. 
Clinical  Examination  of  the  Blood    .         .         .         .181 

CHAPTER    YI. 
Respiratory  System 209 

CHAPTER    Yll. 
The  Urine 267 

CHAPTER    YIII. 

The  Skin ^'^^ 

CHAPTER    IX. 
Nervous  System ^^° 

CHAPTER    X. 

Examination  of  the  Eye,  E.ar,  Throat  .an'D  Nose      .     451 


viii  Clinical   Methods. 

CHAPTER    XI.  PAGE 

LocoMOTORY  System         .         .        .        .         ,        ,        ,481 

CHAPTER    XII. 
The  Clinical  Examination  oe  Children     .         .        ,489 

CHAPTER    XIII. 
The  Examination  of  Pathological  Fluids.        .         .     502 

CHAPTER    XIV. 
Clinical  Bacteriology  . 512 


APPENDIX .     534 

INDEX .544 


LIST    OF    PLATES. 


Bacteria Frontispiece 

Viscera    of   Thorax   and    Abdomen,  as   seen 

from  the  front  ......  To  face  p.     61 

Viscera   of  Thorax   and   Abdomen,   as    seen 

prom  behind         .         .         .         .         .         .     ,,       ,,       65 

Viscera,  from  the  side „       „       69 

Cells    of    Normal  [Blood.     Cells   from   thej 
Blood  in  Spleno-myelogenous  Leuc^mia. 
Cells  from  the  Blood  in  Lymphocyth^mia     ,,       ,,     203 

The  Blood  in  Malaria »       n     205 

Motor  Segmental' Functions  of  the  Cervical 

Enlargement        .         .         .         .         •         •     ??       )>     369 

Motor  Segmental  Functions  of  the  Lumbar 

Enlargement 5>       ?>     ^71 


LIST    OF    ILLUSTRATIONS. 


-»<>•- 


PAOE 

Remittent  fever  (hectic).  Case  of  phthisis       ....  39 

Intermittent  fevers  .........  40 

Crisis.     Case  of  lobar  pneumonia    ......  40 

Lysis.     Case  of  broncho-i^neumonia         .....  41 

Scraping  from  a  patch  of  thrush.     Culture  of  saccharomyces 

albicans  (monilia  Candida) — the  fungus  of  thrush     .         .  44 

Enlargement  of  spleen     ........  69 

Showing  colon  crossing  a  tumour  of  the  kidney       ...  73 

Microscopical  view  of  vomited  matter     .....  83 

Oxyuris  vermicularis  (nat.  size)        .         .         .         .         .         .88 

Oxyuris  vermicularis  (magnified)      ......  88 

Ankylostoma  duodenale  (nat.  size)  .         .         ....  89 

Ankylostoma  duodenale  (magnified)        .....  89 

Trichocephalus  dispar       ........  90 

Cestoda 91 

Ova  of  entozoa          .........  94 

Amoebic  dysentery 95 

The  heart  in  an  infant     ......         .        .  103 

Antero-posterior  section  of  thorax  near  the  left  parasternal 

line 119 

Superficial  and  deep  dulness  of  normal  heart  and  liver  .         .  122 
Aortic  aneurysm      .         .         .         .         .         .         .         .         .124 

Diagram  to  illustrate  the  effect  of  dilatation  of  the  right  and 

left  sides  of  the  heart  respectively 125 

Dilatation  and  hj'pertrophy  of  left  side  of  heart    .         .         .  126 

Dilatation  of  right  side  of  heart       ......  127 

Pericardial  effusion .  128 

Displacement  of  heart  upwards 129 

Displacement  of  heart  and  liver  in  emphysema      .         .         .  130 

Displacement  of  heart  in  right-sided  pleural  effusion     .         .  131 

Displacement  of  heart  in  left-sided  i^leural  effusion        .         .  132 

Cardiac  cycle   ..........  135 

Position  of  the  cardiac  valves  and  auscultatory  ai'eas     .         .  137 

Presvstolic  mitral  murmur 146 


Cl  I  NIC  a  l    Me  thods  . 


-IDroiiagatioii  in  front 
-propagation  behind 


Mitral  systolic  murmur 

Mitral  systolic  murmur 

Aortic  systolic  murmur    . 

Aortic  diastolic  murmur  . 

Pulmonary  systolic  murmur 

Combined  aortic  and  mitral  sj-stolic  mui'murs 

Bigeminal  pulse 

Trigeminal  pulse 

Noi'mal  forms  of  pulse 

Low-tension  pulse    . 

High-tension  pulse  . 

Aortic  stenosis 

Aortic  incompetence 

Aortic  incompetence  ;  compensation  established 

Mitral  incompetence        .... 

Pulse  in  aneurysm 

Aortic  atheroma  (senile  pulse) 

Pulsus  bisferiens 

Dicrotic  pulse  ...... 

Haemocytometer  pipette  (Thoma-Zeiss)  . 

Thoma-Zeiss  counting-slide 

Microscopic  view    of    Thoma-Zeiss    countiu; 

divisions    ...... 

Von  Fleischl's  hpemometer 

Filaria  nocturna 

Embryos  of  filaria  nocturna  in  blood 
Diagram  showing  method  of  making  a  blood 

of  two  slides     . 
Si^ectra  of  hsemoglobin  and  its  derivatives 
Cross  section  of  rachitic  chest 
Cross  section  of  pigeon  breast . 
Traube's  space  in  pleuritic  effusion 
Pleurisy,  with  effusion,  seen  from  behind 
Pleurisy,  with  effusion,  seen  from  the  side 
Pleurisy,  with  effusion,  seen  from  the  front 
Physical    signs    at    beginning,    height    and 

j)neumonia         .         .         .         . 
Physical  signs  at  the  various  stages  of  pleurisy 
Elastic  tissue  from  lung  in  sputum  of  a  case  of  phthisis 
Bronchial  cast  from  a  case  of  plastic  bronchitis 


film 


slide  showing 


decline 


PAGE 

147 

148 

150 

151 

152 

153 

159, 

160 

168 

169 

169 

170 

171 

172 

173 

173 

174 

174 

174 

181 

182 


by  means 


of 


List  of  Illustratioxs. 


XI 


putum 


t'  ill  sputum 


2,  Spectrum  of  urobilin  masked  by 


leucin 


Cursclimainrs  spirals  in  s 

Charcot-Leyden  crystals 

Ova  of  distoma  pulmonal 

Actinomyces  in  sputum 

Aspergillus  fumigatus 

Record  of  pneumonia 

1,  Spectrum  of  urol)ilin  ; 
other  ijigments . 

Urea  nitrate     . 
Gerrard's  ureometer 
Pavy's  api^aratus 
Deposit  in  acid  urine 
Uric  acid , 
Urate  of  soda  . 
Oxalate  of  lime 
Ty rosin  crystals  ;  cystin 
Stellar  phosphates  . 
Trij)le  phosphates     . 
Deposit  in  alkaline  fermentation  of  urine,  showing  urate  of 
ammonia,  triple  phosphates,  and  bacterium  urese 

Renal  eijithelium 

Eijithelial  cells  from  the  urinary  passages 

Tube  casts 

Tube  casts        ..... 

Hyaline  and  waxy  tube  casts  . 

Ova  of  Bilharzia  htematobium  in  urine 

Animal  parasites  of  the  skin   . 

Vegetable  parasites  of  the  skin 

Outer  aspect  of  right  hemisphere,  showing  convolutions 

Outer  aspect  of  left  hemisphere,  showing  functional  areas     . 

Mesial  aspect  of  right  hemisphere,  showing  convolutions 

Mesial  aspect  of  left  hemisphere,  showing  functional  areas     . 

Diagram  to  show  relative  positions  of  the  face,  arm,  and  leg 

fibres  in  their  course  from  cortex  to  crus  . 
Diagram  showing  the  course  of  the  motor  fibres  from  the 

cortex  to  tlie  cord 

Upiper  and  lower  nexu'ons  of  motor  path 

Lateral  view  of  the  skin  areas  supplied  by  the  second,  third, 
and  fourth  cer%^cal  segments     . 

Sensory  segmental  functions  of  the  spinal  cord 


PAGE 

261 
261 

262 
262 
263 
266 

270 
286 
288 
316 
329 
330 
331 
331 
332 
333 
334 

335 
336 
337 
338 
339 
340 
345 
352 
355 
358 
359 
359 
360 

361 

362 
363 

368 
369 


Xll 


Cl  I  NIC  a  l   Me  tho  ds. 


Scheme  of  a  transverse  section  of  the  spinal  cord,  showing  on 
the  left  side  the  positions  of  the  various  tracts,  and  on 
the  right  side  the  names  of  the  diseases  affecting  each 
part 

Cutaneous  nerve  supply  of  upper  limb    ..... 
Cutaneous  nerve  supply  of  lower  limb     ..... 
Distribution  of  the  sensory  nerves  of  the  head 
Showing  the  exact  distribution  of  the  sensory  nerves  of  the 
fingers 

Showing  the  segmental  sensory  supply  of  the  skin  of  the 
hand 

Schematic  figure,  showing  the  com'se  of  the  ojitic  fibres  . 

Diagram  showing  the  connections  of  the  centres  for  contrac- 
tion of  the  pupils      ........ 

Distribution  of  anaesthesia  in  complete  paralysis  of  the  fifth 
nerve  ...... 

Motor  points,  face  and  neck     . 

Motor  points,  back  of  arm 

Motor  points,  front  of  arm 

Motor  points,  front  of  thigh    . 

Motor  points,  back  of  thigh  and  leg 

Motor  jjoints,  side  of  leg .... 

Bordier's  method  of  recording  the  electrical 

muscle,  in  health      .... 
Bordier's  method  of  recording  the  electrical  reactions  of 

muscle,  in  a  case  of  complete  reaction  of  degeneration 

Normal  tympanic  membrane  . 
Diagram  of  larynx   ..... 
Posterior  nares  and  surrounding  parts    . 
Position  of  viscera  in  child  of  five    . 

Foulis'  cells 

Cholesterin  crystals  .... 

Fatty  needles  and  fatty  crystals  in  degenerated  cells 
Colony  of  actinomyces  in  jius,  from  a  case  of  actinomycosis  of 
the  csecum         ......... 

"Widal's  pipette 

Hsemin  crystals 


reactions  of  a 


371 
372 
373 
374 


376 
383 

403 

40(5 
440 
441 
442 
443 
444 
445 

447 

447 
470 
475 
479 
496 
506 
507 
507 

508 
526 
539 


Clinical  Methods. 


CHAPTER     I. 

Case-taking. 

There  can  be  no  question  of  the  value  of  accurate 
and  systematic  case-taking.  It  trains  the  beginner  in 
habits  of  thoroughness  and  exactness  at  the  bedside, 
and  ensures  that  no  point  of  importance  in  the  case  is 
missed.  To  the  more  experienced  clinician  the  sys- 
tematic record  of  cases  is  of  no  less  value.  It  orives 
to  his  experience  a  concrete  embodiment,  so  that  he 
can  draw  upon  it  at  any  future  time  by  the  comparison 
of  new  cases  with  old,  and  so  enables  him  gradually  to 
build  up  his  clinical  knowledge  upon  a  sure  foundation. 
When  we  come  to  the  method  to  be  pursued  in  taking 
a  case,  however,  it  is  a  question  of  '''•  quot  homines,  tot 
sententice.^'  Almost  every  clinical  teacher  has  his  own 
particular  plan  for  investigating  and  recording  a  case. 
Nor  is  it  of  so  much  importance  what  particular  method 
one  adopts,  provided  he  adheres  to  it.  Every  good 
method  of  case-taking  should  be  both  comprehensive 
and  concise.  It  should  be  comprehensive,  so  as  to  be 
capable  of  being  applied  to  every  case  and  of  covering 
all  the  points  in  it ;  it  should  be  concise,  so  as  to  pre- 
sent all  the  important  features  of  a  case  in  as  small 
a  compass  as  possible.  The  question  of  conciseness  is 
of  very  great  importance.  Nothing  is  more  annoying 
than  to  be  obliged  to  wade  through  a  mass  of  verbiage 
in  order  to  get  at  the  chief  facts  of  a  particular  case. 

B 


2  Case-taking, 

The  student  should  practise  the  art  of  focussing  a  case 
in  such  a  way  as  to  present  its  leading  features  in  a 
few  sentences.  For  this  object  the  writing  of  resumes 
of  cases  will  be  found  a  useful  exercise.  He  should 
also  avoid  lengthy  verbal  descriptions  as  far  as  possible, 
especially  where  the  facts  admit  of  graphic  repre- 
sentation. The  outline  diagrams  now  supplied  by 
Messrs.  Lewis,  Danielsson,  and  others  will  be  found 
useful  aids  in  this  respect.  Physical  signs  can  be 
filled  in  on  them  by  means  of  conventional  symbols. 

We  have  appended  to  this  chapter  a  scheme  of 
case-taking  which  meets  all  necessary  requirements. 
At  the  same  time,  it  must  be  used,  like  all  such 
schemes,  with  some  judgment  and  elasticity.  All  the 
points  mentioned  need  not  be  minutely  inquired  into 
in  each  individual  case.  For  example,  if  a  patient  is 
suffering  from  advanced  cardiac  disease,  there  is  no 
use  in  writing  a  minute  description  of  the  state  of  liis 
teeth.  Yet  that  is  the  kind  of  error  into  which  be- 
ginners not  infrequently  fall.  Of  course,  it  demands 
some  experience  to  enable  one  to  say  what  are  the 
points  which  it  is  of  importance  to  inquire  into  in 
any  particular  case,  and  at  first  one  may  sometimes 
be  at  fault ;  but  the  application  of  a  little  common- 
sense  will  ensure  the  avoidance  of  any  gross  blunders. 

The  "  taking  "  of  any  case  consists  of  two  parts — 
(1)  The  interros^atioii  of  the  patient;  (2)  The 
physical  examination. 

The  object  of  the  interrogation  of  the  patient  is  to 
elicit  information  regarding  his  present  illness  and  the 
state  of  his  previous  health  and  that  of  his  family. 
The  interrogation  must  be  pursued  with  patience,  the 
patient  being  allowed,  as  far  as  possible,  to  tell  his 
story  in  his  own  words.  Two  good  rules  should  be 
remembered — firstly,  to  avoid  leading  questions ;  and, 
secondly,  never  to  ask  the  same  question  twice.  The 
use  of  leading  questions  is  only  occasionally  allowable, 


Interrogation  of  Patient.  3 

as,  for  instance,  when  one  suspects  that  he  has  to  do 
with  a  case  of  malingering,  wlien  one  may  get  the 
patient  to  assert  the  existence  of  contradictory  symp- 
toms, so  confirming  one's  suspicions.  It  may  also  be 
necessary  in  dealing  with  patients  who  are  stupid 
either  by  nature  or  as  the  result  of  disease.  When 
one  is  trying  to  elicit  what  are  known  as  "  subjective 
symptoms,"  the  use  of  leading  questions  may  also  be 
admissible.  It  is  important  to  avoid  asking  the  same 
question  twice,  because  to  do  so  looks  careless,  and 
conveys  to  the  patient  the  impression  of  taking  but  a 
languid  interest  in  his  case. 

We  may  proceed  now  to  go  more  into  detail  re- 
garding the  questions  which  should  be  asked.  In 
doing  so,  we  shall  consider  first  the  questions  which 
one  has  to  put  in  every  case — what  one  may  call 
the  general  interrogation — and  then  we  shall  take  up 
the  questions  which  have  to  be  put  in  examining 
cases  of  disease  affecting  the  different  systems  or 
organs ;  this  may  be  called  the  si^ecial  interrogation. 

1.  Oeneral  interrog-ation. — Begin  by  ascer- 
taining the  patient's  name,  age,  occupation,  and  whether 
he  is  married  or  single.  It  is  also  of  importance  to 
note  his  exact  postal  address  for  purposes  of  future 
communication. 

Two  important  questions  then  follow — (1)  Of  what 
does  he  complain  %  (2)  How  long  have  the  symptoms 
been  present  ?  Having  thus  defined  his  complaint  and 
its  duration,  proceed  to  ascertain  the  chief  facts  in  his 
history. 

The  most  logical  plan  is  to  take  \hefa7nily  history 
first.  It  is  usually  suflBcient  to  inquire  regarding  the 
state  of  health  or  cause  of  death  of  the  immediate 
relatives  only — the  parents,  brothers  and  sisters, 
and,  if  the  patient  be  married,  of  his  own  children, 
if  he  has  any.  These  facts  tell  us  whether  he  is 
predisposed  by  heredity  to  any  particular  disease. 


4  Case-taking. 

One  may  then  pass  to  his  personal  history.  Here 
it  is  well  to  begin  with  what  may  be  grouped  together 
as  the  patient's  environment,  or  surroundings  and 
habits.  This  includes  inquiry  into  [a)  the  exact  nature 
of  his  occupation,  and  whether  or  not  it  exposes  him 
to  injurious  influences ;  (h)  his  home  surroundings, 
their  sanitary  condition  or  otherwise ;  (c)  the  amount 
of  exercise  he  takes  ;  (d)  the  nature  of  his  food,  and 
the  amount  of  his  indulgence  in  such  articles  as  alcohol, 
tea,  and  tobacco.  Regarding  alcohol,  it  is  important 
to  ascertain  not  merely  how  much — e.g.  how  many 
glasses  of  spirits  per  day — the  patient  takes,  but  how 
and  when  he  consumes  it — e.g.  with  or  between  meals. 
The  kind  of  tobacco  he  smokes  and  the  number  of 
ounces  consumed  per  week  may  require  to  be  ascer- 
tained in  some  cases,  (e)  One  should  always  ascertain, 
lastly,  whether  or  not  he  has  ever  lived  abroad,  and,  if 
so,  in  what  part  of  the  world. 

The  information  thus  acquired  enables  one  to  add 
to  the  tendencies  to  disease  which  the  patient  has  in- 
herited, those  which  he  has  acquired  from  his  environ- 
ment and  personal  habits. 

One  should  take  up  next  the  question  of  the 
patient's  previous  health.  Ascertain  wiiat  illnesses 
he  has  had,  when  he  had  them,  their  duration,  and 
wdiether  or  not  his  recovery  from  them  was  complete. 
It  is  usually  necessary  to  inquire  directly  as  to 
whether  or  not  the  patient  has  ever  had  syphilis.  It 
is  not  sufficient  to  ascertain  that  he  has  had  a  sore ; 
the  question  of  secondary  symptoms— e.p'.  rash — must 
also  be  gone  into.  If  the  patient  denies  syphilis,  it 
may  be  necessary  to  ask  whether  or  not  he  has  ever 
been  exposed  to  the  risk  of  it,  and  whether  or  not  he 
has  had  any  other  venereal  disease.  In  the  case  of 
female  patients,  information  regarding  venereal  disease 
should,  as  far  as  possible,  be  obtained  indirectly, 
direct  interrogation  on  the  subject  being  employed 


Interrogation  of  Patient.  5 

only  when  a  definite  history  is  absolutely  necessary 
for  the  elucidation  of  the  case.  The  student  need 
hardly  be  reminded  that  even  under  these  circum- 
stances his  questions  should  be  put  as  delicately  as 
possible. 

Having  now  ascertained  the  patient's  inherited 
and  acquired  tendencies,  and  the  seeds  of  disease 
which  may  have  been  sow^n  in  him  by  his  previous 
illnesses,  ^ye  are  ready  to  acquire  information  re- 
garding his  present  disorder. 

Ask  how  and  when  it  began,  whether  suddenly  or 
gradually;  what  was  the  first  thing  he  noticed  wrong; 
what  has  been  the  order  of  appearance  of  his  symp- 
toms, and  which  are  those  that  chiefly  trouble  him 
at  the  present  time.  Ascertain  whether  or  not  he  has 
already  been  under  treatment,  and,  if  so,  what  has 
been  done  for  him. 

This  exhausts  the  general  interrogation,  and  in- 
cludes the  chief  facts  that  have  to  be  inquired  into 
in  every  case. 

2.  The  special  iiiterrog:atio]i,  to  which  we  have 
already  referred,  must  be  modified  according  to  the 
particular  organ  which  is  believed  to  be  affected  and 
the  nature  of  the  disease  of  which  it  is  suspected  to 
be  the  seat.  It  is  here  that  the  student  has  most 
diflS.culty.  It  is  only  by  experience  that  one  can  tell 
what  it  is  essential  to  ask  in  each  individual  case.  In 
order  to  help  the  beginner,  however,  we  have  drawn 
up  for  his  guidance  a  scheme  of  interrogation  which 
he  can  pursue  when  he  has  reason  to  suppose  that  the 
patient's  general  symptoms  point  to  an  affection  of 
any  particular  system  or  organ.  Such  a  scheme  is 
necessarily  very  far  from  complete,  and  may  require 
to  be  supplemented  in  individual  cases.  Nor  is  one 
able  in  such  a  work  as  this  to  explain  why  such  and 
such  questions  should  be  put  in  affections  of  this  or 
that  organ  or  system.      The  reasons  for  the  questions 


6  Case-taking. 

the  student  will  find  out  for  himself  in  due  time.  Our 
present  object  is  merely  to  help  him  in  the  interroga- 
tion of  his  earlier  cases,  so  that  he  may  not  miss  any 
important  facts.  The  questions  are  to  a  consider- 
able extent  concerned  with  eliciting  what  are  some- 
times spoken  of  as  "  subjective  symptoms" — i.e.  the 
morbid  sensations  experienced  by  a  patient  as  the 
result  of  the  disease  of  some  organ  or  system. 

In  making  the  notes,  these,  along  with  the  other 
replies,  should  be  entered  under  the  special  system  to 
which  they  refer. 

1.  Alimentary  syisteiii  and  abdomen. 

(a)  Symptoms  point  to  an  affection  of  the  stomach. 
Inquire  regarding — 

Ajypetite. — Is  it  excessive,  diminished,  or  capricious  F  Does 
it  increase  on  eating  ?     Does  he  suffer  from  thirst  ? 

Meals. — Arrangement  of  these ;  the  nature  of  the  food. 
Does  he  eat  between  meals  ? 

Sensations  referred  t"  stomaoh. — Their  nature,  and  where 
exactly  they  are  felt.  ITieir  relation  to  the  taking  of  food ; 
are  they  produced  or  relieved  by  it  ?  How  long  after  food  do 
they  come  on  ?  Are  they  specially  influenced  by  different 
kinds  of  food  ? 

Vomiting. — Frequency  and  time  of ;  by  day  or  by  night ; 
in  the  morning  or  in  the  evening.  Its  relation  to  food ;  is  it 
only  after  food,  or  does  it  occur  at  other  times  ?  Its  relation 
to  pain ;  does  it  relieve  pain  or  not  ?  Does  patient  strain  and 
retch  much,  or  does  the  vomited  matter  come  up  quite  easily  ? 

General  characters  of  vomited  matter. — Its  amount  and 
colour.  Is  there  ever  "  coffee-grounds  "  vomiting  ;  is  it  ever 
sour  and  frothy  ? 

Eructations. — Presence  or  absence  ;  have  they  any  taste  ? 

Flatulence. — Presence  or  absence ;  after  food  only  or 
between  meals  ?  Relation  to  particular  articles  of  food.  Does 
it  tend  to  escape  downwards  or  upwards  ? 

State  of  the  bowels.* — How  often  are  they  opened?  Any 
special  characters  of  the  motions. 

*  While  the  methods  of  gynecological  examination  are  beyond 
the  scope  of  this  book,  yet  it  must  not  be  forgotten  that  it  is 
frequently  necessary  in  piu-ely  medical  cases  to  inquire  regarding 
the  menstrual  function.     The  cases  in  which  such  inquiry  may  be 


Inter ROG AT/OX  of  Patient.  7 

id)  Symptoms  point  to  an  affection  of  the  intes- 
tines.     Inquire  regarding — 

Diarrhfva. — Its  frequency  and  its  relation  to  meals  or  to 
special  articles  of  food.  Character  of  the  motions.  Has  he 
ever  passed  .any  blood  or  slime  ?  Is  there  any  straining  during 
defaK-ation  r     Is  there  any  flatulence  ': 

Constipation. — "What  is  his  usual  habit  r  are  the  bowels 
opened  regularly,  and  if  so,  how  often  r  How  long  since  the 
last  motion  r  Has  he  ever  noticed  any  grooA-ing  or  flattening 
of  the  motions?  Does  the  constipation  alternate  with  diar- 
rhcea  r     Has  he  any  griping  pain  r     Has  he  had  any  vomiting  r 

Pain. — Character;  persistent  or  intermittent.  Where  is  it 
felt  worst  ?     Is  it  relieved  or  aggravated  by  pressure  ? 

(c)  Symptoms  point  to  an  affection  of  the  liver 
— e.g.  patient  is  jaundiced,  or  lias  pain  in  region  of  liver. 
Inquire  regarding — 

Pain. — Its  site.  Has  he  ever  any  attacks  of  very  severe 
pain,  coming  on  suddenly  and  lasting  for  a  few  hours  ?  If  so, 
did  the  pain  radiate,  and  in  what  direction  ?  Was  there  vomit- 
ing with  it  r  Was  he  yellow  at  all  after  it  subsided  r  Has  he 
ever  pain  in  the  tip  of  the  shoulder  "r 

Does  he  suffer  from  piles  r 

Does  he  ever  vomit  blood  ? 

Has  he  noticed  any  change  in  the  colour  of  the  urine  or 
faeces  ? 

Does  his  skin  itch  at  all  (if  he  is  jaundiced)  ?     Inquire  also 

required  are  too  diverse  to  be  enumerated  here.  It  need  hardly 
be  said  that  the  necessary  questions  should  not  be  abruptly 
X)ut  to  the  patient,  but  shoulcl  be  delicately  led  up  to.  Having 
inquired  regarding  the  regularity  of  the  bowels,  one  may  ask  if 
the  patient  is  "regular  in  her  own  health,"  or  "regular  in  her 
unwell  times."'  It  will  be  remembered  that  in  a  majority  of  cases 
menstruation  recurs  every  tw^enty-eight  days,  but  the  intervals 
may  be  longer  or  shorter  according  to  the  patient's  habit.  If 
menstruation  has  ceased,  one  must  inquire  how  long  it  has  been 
absent.  Normally  the  cessation  of  menstruation,  or  menopause, 
should  not  occiir  till  about  the  forty-fifth  year.  It  is  also  necessary 
to  inquire  whether  the  patient  is  losing  more  or  less  blood  than 
usual.  This  is  specially  indicated  in  cases  of  an?emia.  If  the 
menstrual  flow  lasts  for  less  than  two  or  more  than  eight  days,  it 
is  to  be  regarded  as  abnormal.  The  presence  or  absence  of  pain  at 
the  j)eriod  is  also  a  poiut  of  some  importance.  The  age  at  which 
menstruation  began,  and  the  occurrence  or  not  of  intermenstrual 
leucoiThcta  ("  white  discharge  ")  must  sometimes  be  inquired  into. 


8  Case-taking. 

regarding  his  digestion  on  the  lines  of  the  interrogation  already 
laid  down  for  affections  of  the  stomach. 

2.  The  symptoms  point  to  an  affection  of  the 
circulatory  system. 

Inquire  regarding — 

h.  family  lihtory  of  gout,  rheumatism,  angina,  apoplexy,  or 
heart  disease, 

A  personal  history  of  rheumatic  fever,  St.  Vitus*  dance, 
scarlatina,  or  diphtheria.  (If  a  child,  ask  also  about  sore  throats 
and  "  growing  pains  "). 

The  following  subjective  sensations  : — 

Dyspnoea. — Has  he  to  sit  up  in  bed,  or  can  he  sleep  lying- 
down  ?  When  does  it  come  on  ?  Frcecordial  pain  or  distress ;  its 
exact  site  and  character ;  does  it  radiate  or  not  ?  If  so,  in  what 
dii^ection  ?  Palpitation :  its  relation  to  meals,  and  to  exertion. 
Does  the  heart  give  an  occasional  thump  now  and  then  ? 
Sleep,  good  or  bad ;  does  he  di-eam  ?  Giddiness,  is  it  ever 
present,  and  when  ? 

Ask  also  for  signs  indicative  of  general  venous  distension 
— e.g.  do  the  feet  ever  swell  ?  Has  he  any  cough  ?  What  is 
the  state  of  the  digestion  ?     Does  his  nose  ever  bleed  ? 

3.  The  symptoms  and  appearances  point  to  an 
affection  of  the  blood.     Inquire  regarding — 

Family  history  of  bleeders.  Has  he  had  any  loss  of  blood  ? 
Has  he  bleeding  piles  ?  (If  a  woman — is  menstruation  ex- 
cessive or  diminished?)     What  is  the  state  of  the  bowels  ? 

Any  possibility  of  lead  poisoning  or  malaria  ? 

Such  subjective  sensations  as  breathlessness  on  exertion  ; 
headache ;  giddiness. 

Do  the  feet  ever  swell  ? 

4.  The  symptoms  point  to  an  affection  of  the 
respiratory    org'ans.     Inquire  regarding — 

Family  history  of  bronchitis,  asthma,  phthisis,  or  "  scro- 
fula." The  patient's  occupation  ;  does  it  expose  him  to  the 
inhalation  of  irritating  fumes  or  particles  ?  Has  he  ever  had 
large  glands  in  the  neck  ?  Does  he  sweat  at  night  ?  Is  he 
getting  thinner  ? 

Co'uyh. — Its  character  and  frequency  ;  when  is  it  worst  ? 
Does  it  pain  him  or  not  ?     Does  he  ever  vomit  with  it  ? 

lExjyectoration. — Its  amount  and  general  characters ;  yellow 
or  not  ?  Ever  blood  in  it  ?  If  so,  is  it  only  after  severe 
coughing  ?     Is  the  blood  bright  and  frothy  or  dark  in  colour  ? 


Interrogation  of  Patient.  9 

Pcbiih  in  chest. — Is  it  aggravated  by  taking  a  brcith!-' 
Constant  or  not  ?     Where  seated  ? 

Di/sjmoea. — "\\Tien  is  it  felt ':  If  spasmodic,  ask  him  to 
describe  an  attack. 

5.  The  symptoms  })oint  to  an  atFection  of  the  Kid- 
neys— e.g.  general  dropsy — or  iiriiiary  passages 

— e.g.  pain  in  micturition.     Inquire  regarding — 

Family  history  of  Bright's  disease,  gout,  or  apoplexy. 

Personal  history  of  scarlatina,  syphilis,  lead-poisoning,  pro- 
longed suppurations,  gravel  or  gout,  and  previous  renal  disease. 

Has  he  any  pain  in  the  lumbar  region  ?  Ever  any  attacks 
of  acute  pain  shooting  down  into  the  groin  ? 

The  following  remote  symptoms  : — 

Headache,  vomiting,  drowsiness,  paralysis  or  fits,  dimness 
of  sight,  dyspnoea. 

Does  the  face  ever  look  puJffy  in  the  morning  P 

What  is  the  state  of  the  bowels  ? 

Inquire  regarding  micturition  as  follows  : — 

Urine. — Is  it  altered  in  amount  P  Has  he  to  rise  in  the 
night  to  pass  it  ? 

Is  it  altered  in  colour  ?  Is  it  clear  or  turbid  when  passed? 
Ever  any  blood  in  it  r  If  so,  at  what  period  of  micturition  is 
it  present  ? 

Is  there  any  increased  frequency  of  micturition  ?  Is  the 
increase  by  day  or  by  night  r 

Is  there  any  pain  during  mictuiition  ?  is  it  before,  during, 
or  after  the  act  ?  What  is  its  character,  and  where  is  it  felt  ? 
Is  it  aggravated  by  movement  ? 

6.  In  sliiii   diseases. 

Inquire  carefully  into  the  patient's  personal  habits  as 
regards  diet,  clothing,  and  washing.  Ask  if  he  has  been  taking 
any  drugs  recently.  It  may  be  necessary  to  inquire  carefully 
regarding  syphilis.  Does  the  eruption  itch  ?  If  so,  when  is 
the  itching  worst  ?  Did  the  eruption  appear  all  at  once  or  in 
crops  r  (Family  history  of  gout ;  previous  history  of  rheuma- 
tism, anaemia,  etc.) 

7.  The  symptoms  point  to  an  affection  of  the 
nervous  system. 

Inquire  regarding — 

A  family  history  of  mental  disease,  St.  Vitus'  dance, 
paralysis,  or  fits. 


I  o  Ca  S£-  ta  king, 

» 

The  nature  of  the  patient's  work ;  is  he  exposed  to  any 
poisons — e.g.  lead,  mercury,  arsenic,  naphtha,  etc.  Syphilis 
and  alcohol  should  be  inquired  about  with  special  care. 

In  cerebral  cases  it  is  often  very  important  to  inquire  re- 
garding- discharge  from  the  ear. 

Should  he  complain  of  fits,  the  following  questions  should 
be  asked : — 

Age  at  first  fit  ?  Any  assigned  cause  ?  Describe  the  first 
fit.  When  did  the  second  occur  ?  What  has  been  shortest  and 
longest  interval  between  the  fits  ?  Are  they  more  or  less 
frequent  now  ?  Do  they  occur  in  sleep  or  not  ?  Has  he  any 
premonition  or  aura  ?  Is  the  onset  sudden  or  gradual  ?  Are 
convulsions  present  ?  Are  they  uni-  or  bi-lateral  ?  Where  do 
they  begin  ?  Does  he  bite  his  tongue,  micturate,  or  deftecate 
during  the  fit  ?  Is  restraint  necessary  during  the  fit  in  order  to 
prevent  him  from  hurting  himself  ?  How  does  it  end — sponta- 
neously, oris  it  induced  ?  Are  there  any  after- symptoms,  such 
as  sleep,  headache,  or  automatism  ? 

If  he  complains  oi  paralysis,  inquire  regarding — 

Symptoms  of  heart  disease,  or  chronic  renal  disease  {see 
Circulatory  and  Urinary  Systems).  Had  he  any  premonitory 
symptoms  before  the  onset  ?  Has  he  any  headache  or  vomit- 
ing ?  Where  is  the  headache  situated  ?  Has  he  any  giddiness 
or  difiiculty  in  walking  ?  (The  method  of  eliciting  other  sub- 
jective symptoms  of  nervous  disease  is  considered  along  with 
the  investigation  of  the  cranial  nerves). 

8.  The  symptoms  point  to  an  affection  of  the 
bones  or  joints. 

Inquire  specially,  in  the  family  history,  for  tubercular 
disease,  rheumatism,  gout,  or  syphilis,  and  in  the  personal 
history  for  tubercular  disease,  previous  manifestations  of  gout 
or  rheumatism,  for  syphilis  or  gonorrhoea,  and  for  any  remote 
or  recent  injury  (and  in  a  woman  for  leucorrhoea  or  post-partum 
trouble). 

If  there  be  pain  referred  to  a  bone,  ask  whether  it  is  worse 
during  the  day  or  during  the  night.  If  the  pain  be  in  a  joint, 
ask  whether  it  is  constantly  present  or  only  when  the  joint  is 
moved.  Are  there  any  starting  pains  at  night  ?  Is  the  pain 
affected  by  weather?  Does  the  pain  shift  from  one  joint  to 
another  ? 

If  the  patient  be  a  young  cliild,  the  following 

special  questions  should  be  put  to  the  mother : — 

How  many  other  children  are  there  ?     Any  dead,  and  of 


Physical  Examination.  ii 

what  ?  Where  does  patient  come  in  the  family  \  Has  there 
been  any  miscarriages  ?  If  so,  when  ?  Health  of  father's  and 
mother's  family  ? 

Was  this  a  full-time  child  ?  Was  the  labour  normal  /  Was 
the  child  breast-fed ;  if  so,  how  long  ?  If  not,  how  was  it  fed  ? 
"SMiat  food  does  it  get  now  ?  Had  it  any  rash  after  birth,  or 
any  snuffles  ?     When  did  it  begin  to  get  its  teeth  and  to  walk  / 

AVhat  previous  illnesses  has  it  had  ?  (Inquire  especially 
about  the  acute  specific  fevers.)  If  the  child  is  suffering  from 
cough,  inquii-e  specially  whether  it  has  ever  whooped,  when  the 
cough  is  worst,  and  whether  the  child  is  ever  sick  after  it. 

The  interrogation  of  the  patient  being  completed, 
one  proceeds  to — 

2.  The  physical  examiiiatioii. 

One  investigates  first  of  all,  in  every  case,  the 
patient's  general  state.  This  includes  the  general 
condition  of  his  nutrition,  the  presence  of  any  ob- 
viously morbid  appearances,  and  the  other  points 
considered  in  detail  in  Chap.  II.  One  proceeds  after 
that  to  the  investigation  of  each  system  by  itself. 
What  system  should  be  taken  up  first  ?  As  regards 
this,  there  are  two  possible  methods.  One  may  either 
take  up  the  systems  in  one  and  the  same  order  in 
every  case,  beginning,  say,  with  the  Alimentary,  or 
one  may  examine  first  the  system  which  is  most 
affected.  The  latter  is,  on  the  whole,  the  better  plan, 
provided  always  that  one  is  able  to  tell  which  system 
it  really  is  which  is  most  diseased.  The  advantage 
of  this  method  is  that  it  gives  most  prominence  to  the 
most  important  part  of  the  physical  examination. 
Whichever  plan  the  student  elects  to  adopt,  he  may 
now  proceed  to  the  physical  examination  of  the 
different  systems  in  accordance  with  the  instructions 
laid  down  in  the  following  chapters,  the  results  being 
noted  in  the  order  given  in  the  scheme  below. 

Only  one  more  point  regarding  case-taking  remains 
to  be  emphasised,  and  that  is  the  importance  of  noting 
negative  as  well  as  positive  facts.     It  is  often  quite 


12  Case-taking. 

as  essential,  for  example,  to  state  that  such  a  symptom 
as  dyspnoea  is  absent  as  to  record  the  fact  of  its 
presence.  This  is  a  point  the  importance  of  which  is 
apt  not  to  be  fully  appreciated  by  the  beginner. 

In  conclusion,  it  need  hardly  be  said  that  the 
examination  should  be  carried  out  as  gently  as 
possible,  all  unnecessary  exposure,  exhaustion,  or 
chilling  of  the  patient  being  carefully  avoided.  If 
the  patient  is  suffering  from  severe  or  acute  disease, 
it  may  be  advisable  to  postpone  all  physical  examin- 
ation other  than  that  which  is  absolutely  necessary  to 
the  diagnosis  of  his  condition,  or  for  guidance  in 
treatment.  It  should  also  be  borne  in  mind  that 
when  a  patient  is  much  exhausted,  or  suffering  from 
serious  disease  of  the  lungs  or  heart,  very  dangerous 
and  even  fatal  results  may  ensue  if  he  be  thoughtlessly 
made  to  sit  up  in  bed  in  order  to  Lave  his  chest 
examined. 

CASE-TAKING     SCHEME. 
1.  INTEREOGATION. 

Name.  Age.  Occupation.  Married  or  single.  Address. 
Date  of  coining  under  observation. 

Complaint. 

Duration. 

Family  history. — Inquire  regarding  parents,  brothers 
and  sisters,  and  patient's  own  children.  Note  state  of  their 
health,  or  the  cause  of  their  death,  with  age  at  which  they 
died. 

Personal  history. 

Environment. — Nature  of  work  and  its  surroundings. 
Hygienic  conditions  at  home ;  habits  as  to  exercise,  food,  tea, 
alcohol,  and  tobacco. 

Previous  illnesses  or  accidents  (if  any),  with  their  time  of 
occurrence,  duration,  and  results. 

Present  illness.— Time  and  mode  of  its  origin,  the  order  in 
which  symptoms  appeared,  and  the  chief  symptoms  which 
trouble  patient  now ;  treatment  (if  any)  already  employed. 


CASE-TAKI^G  Scheme.  13 

2.  PHYSICAL  EXAMINATION. 

1.  Present  state. 

General  condition.  —  General  state  of  consciousness  and 
intelligence.  Decubitus  (if  in  bed),  or  attitude  and  gait  (if 
up).  General  state  of  development  and  nutrition.  Expression 
of  face ;  presence  or  absence  of  pallor,  jaundice,  cyanosis, 
dropsy,  or  trophic  changes.  Presence  or  absence  of  any  si^ecial 
characters  of  the  hands  (p.  29).  Glandular  enlargements. 
Character  of  the  respiration,  and  the  presence  or  absence  of 
cough.     Take  the  temperature. 

2.  Aliuieiitary  system. 

Subjective  symptoms  (see  special  interrogation). 

Examine  the  mouth  (including  the  teeth,  gums,  and 
tongue),  fhepliarynx,  and  fauces  (pp.  42-46),  and  the  cesojyJtagus 
(with  use  of  sound  if  necessary)  (p.  47). 

General  inspection,  palpation  and  percussion  of  the  abdo- 
men (pp.  51-60). 

Stomach. — Palpation  and  Percussion  (pp.  60-64).  Exami- 
nation of  gastric  contents  (test  breakfast)  or  vomit. 

Intestines. — Investigation  of  (p.  74).  Eectal  examination 
if  necessary  (p.  75).     Examination  of  faeces  (p.  84). 

Liver  and  Gall  Bladder. — Examination  of  by  palpation 
and  percussion  (pp.  64-68). 

Spleen. — Examination  of  (p.  69). 

3.  Circulatory  system. 

Hea/rt. — Subjective  Symptoms  (see  special  interrogation). 

Inspection  and  palpation  of  pnecordia,  noting  position  and 
character  of  apex  beat,  presence  or  absence  of  epigastric  pul- 
sation or  prascordial  thrills,  or  of  pulsation  in  the  neck  or  at 
the  base  of  heart. 

Percussion  of  Heart  (p.  117). 

{a)  Upper  border  ] 

(J)  Right  border   >  superficial,  deep. 

\c)  Left  border     ) 

Auscultation  of  Heart  (p.  132). 

{a)  At  apex  and  a  little  internal  to  it. 

(b)  Tricuspid  area  at  lovrer  end  of  sternum. 

(c)  Aortic  area. 

{d)  Pulmonary  area  and  a  little  outside  it. 
[e)  Between  base  and  apex  (third  and  fourth  left  costal 
cartilages.) 

(/)  Veins  and  arteries  of  neck. 

If  a  bruit  is  heard,  note  : —  -  - 


14  Case-taking. 

{a)  Its  time. 

{h)  Its  character  (musical,  harsh,  etc.). 

(e)  Its  point  of  maximum  intensity. 

\d)  Its  direction  of  propagation. 

Pulse. — Describe  its  rate  and  its  rhythm.  Compare  the 
force  of  successive  beats.  Ascertain  the  state  of  the  vessel 
waUs.  Note  the  blood  pressure  during  and  between  the  beats. 
Observe  the  amplitude  of  the  pulse  waves.  Analyse  a  complete 
beat  of  the  pulse  regarding  rise,  maintenance,  and  fall  of  pres- 
sure, and  determine  the  presence  or  absence  of  secondary  waves. 

4.  The   blood. 

Estimate  the  red  and  white  corpuscles  (pp.  181-188).  Esti- 
mate the  hgemoglobin  (pp.  189-192).  Examine  the  blood 
microscopically,  making  films  if  necessary  (pp.  193-208). 

5.  Respiratory  system.  .  ,-*- 

Subjective  symptoms  (see  special  interrogation).  V','^J-n6    v) 

Count  the  respirations  and  describe  their  character.     U 

Inspection  of  chest,  noting  its  shape,  power  of  expansion, 
etc.  (p.  213). 

Mensuration  of  the  two  sides  of  the  chest. 

Palpation  of  chest  (expansion  and  vocal  fremitus)  (p.  223). 

Percussion  of  lungs  anteriorly,  laterally,  and  posteriorly 
(p.  229). 

Auscultation  of  lungs  in  same  order  (p.  240),  noting — 

{a)  Type  of  breath  sounds. 

(&)  Character  of  vocal  resonance. 

{o)  Presence  or  absence  of  accompaniments. 

Sputum. — Note  its  naked  eye  and  microscopic  characters 
(p.  256). 

6.  Urinary  system. 

Palpate  the  Kidmeys  (p.  72). 

Examine  the  ?7rme.  —  Physically  (p.  267),  chemically 
(p.  278),  microscopically  (p.  329),  making  a  note  in  every 
case  of  the  following  points — 

Quantity  in  twenty-four  hours,  colour,  specific  gravity, 
reaction,  odour,  general  character  of  deposit. 

Amount  of  urea.  Presence  or  absence  of  albumin,  blood, 
sugar,  and  bile. 

Microscopic  characters  of  deposit. 

7.  Skin. 

General  colour  ;  presence  or  absence  of  pigmentation  or 
eruption ;  nature  of  "  primary  lesion "  in  eruption  and  of 
"  secondary  lesions,"  if  present  (pp.  347-357). 


Case-taking  Scheme.  15 

Palpate  the  skin ;  dryness,  smoothness,  thickness,  elasticity. 
Character  of  subcutaneous  tissues. 

8.  Nervous  system. 

Inquire  regarding  suhjective  Bymptoms  (see  special  interro- 
gation). 

Investigate  state  of — 

(1)  Intellectual  functions  (intelligence,  memory,  sleep, 
coma,  delirium,  speech,  etc.)  (Chap.  IX,). 

(2)  Cranial  nerve  functions  (testing  them  in  order)  (p.  3S7). 

(3)  Motor  functions  (noting  presence  or  absence  of  paralysis, 
or  of  abnormal  muscular  movements,  and  state  of  muscular 
nutrition)  (pp.  378-386). 

(4)  Sensory  functions  (including  condition  of  sensibility  to 
touch,  weight,  temperatui-e,  and  pain,  and  the  muscle  sense) 
(pp.  427-431) ;  presence  or  absence  of  abnormal  sensations 
(p.  431). 

(5)  Eeflex  functions — 
Superficial  reflexes  (p.  431). 
Deep  „        (p.  434). 
Organic  ,,        (p.  439). 

(6)  Electrical  reactions  of  muscles  and  nerves  (if  necessary) 
(p.  440). 

9.  The  eye. 

Appearances  seen  on  ordinary  inspection  of  lids,  conjunctiva, 
cornea,  etc.  (p.  451). 

Use  oblique  illumination  and  ophthalmoscopy,  noting  state 
of  media,  refraction,  and  characters  of  fundus  (pp.  454-464). 

N.B. — The  fundus  of  the  eye  should  be  reported,  on  in  all 
cases  of  nervous  disease. 

The  Ea,r. — Examine  pinna,  meatus,  and  membrane  (using 
speculum  and  inflation  if  necessary)  (p.  468). 

The  Tliroat,  nose,  and  larynx. — Examine  larynx 
(laryngoscopy)  and  anterior  and  posterior  nares  (posterior 
rhinoscopy)  (pp.  472-480),  noting  any  abnormalities. 

10.  L<ocomotory   system. 

Describe    any   changes   in   the   bones   or  joints    (p.    481). 
Describe  character  of  gait,  if  altered  (p.  485). 
Diag^nosis. 
(Prognosis.) 

Notes  of  Treatment  and  Progress. 

(Daily  notes  in  acute  cases ;  in  others  make  a  note  of  progress 

every  three  days.) 

State  on  dismissal. 

If  patient  died,  add  notes  of  post-mortem  (if  held) . 


i6 


CHAPTER  IT. 

GrENERAL    CONDITION    AND    APPEARANCES. 

Before  commencing  the  physical  examination,  the 
physician  may  gather  invaluable  information  from 
a  more  general  survey  of  his  patient.  During  the 
time  occupied  in  asking  questions,  and  even  before 
it,  the  skilled  eye  and  ear  may  detect  much  that 
has  an  important  bearing  on  the  case.  Experience  in 
actual  clinical  practice  can  alone  educate  to  this,  but 
some  lines  may  be  indicated  along  which,  to  work.* 

One  of  the  first  things  to  observe  is  the  attitude 
of  the  patient  as  he  lies  in  bed  (decubitus).  In 
health  a  person  lies  in  any  manner  which  he  feels 
comfortable — ^sometimes  on  his  back,  sometimes  on  his 
side.  He  changes  his  position  without  much  diffi- 
culty from  time  to  time,  and  has  no  hesitation  in 
altering  his  attitude  if  he  slips  from  his  pillows  or 
feels  otherwise  uncomfortable.  But  the  stress  of 
disease  will  often  confine  his  activity  in  narrow 
bounds.  When  fever  has  run  high,  or  when  some 
other  cause  has  reduced  the  patient  to  extreme  weak- 
ness and  dulled  his  consciousness,  he  no  longer  makes 
an  effort  to  secure  a  position  of  comfort,  but  passively 
slij^s  downwards  from  his  pillows  in  obedience  to  the 
law  of  gravity,  and  lies  huddled  up  near  the  foot 
of  his  bed,  listless,  flaccid,  and  silent,  even  where  the 
attitude  is  such  as  to  render  the  act  of  breathing 
unnecessarily  exhausting. 

Almost  equally  characteristic  is  the  lateral  'position 

*  For  much  fuller  information  than  can  be  given  here,  the 
senior  student  is  referred  to  Fothergill's  "  Physiological  Factor  in 
Diagnosis,"  and  to  the  writings  of  Hutchinson,  Gairdner,  and 
Laycock. 


Attitude  of  Patient.  17 

necessitated  by  some  diseases  of  the  viscera,  and 
especially  by  those  of  tlie  lungs  and  pleura.  The  two 
main  factors  in  compelling  this  attitude  are,  firstly, 
the  greater  ease  with  which  respiration  can  be  per- 
formed on  one  side  than  on  the  other  ;  and,  secondly, 
the  fact  that  in  certain  positions  the  pain  is  rendered 
less  acute,  whilst  in  others  it  is  aggravated.  When 
these  factors  co-operate,  it  is  easy  to  say  which  side 
the  patient  will  choose.  Thus,  in  pleurisy  with  much 
effusion,  where  the  chief  difficulty  is  the  mechanical 
one  of  providing  sufficient  expansion  for  the  unin- 
jured lung,  and  where  pain  is  slight  or  absent  alto- 
gether, the  patient  will  be  found  lying  on  the  diseased 
side.  If,  however,  pain  be  the  prominent  element,  as 
occurs  in  the  earlier  stage  of  pleurisy,  he  will  best 
secure  easy  respiration  by  lying  in  the  position  of  least 
suffering.  What  this  position  will  be  it  is  not  easy  to 
predict,  for  the  pain  depends  both  on  the  amount  of 
movement  and  the  pressure  exerted  by  the  inflamed 
surfaces  on  each  other.  When  the  inflamed  pleura  is 
uppermost  its  movement  is  greatest,  but  its  pressure 
against  the  chest-wall  is  least;  when  it  is  lowermost 
the  opposite  is  true;  and  so  when  movement  is  the 
chief  cause  of  pain  the  patient  will  lie  on  the  affected 
side,  but  when  pressure  exerts  the  greater  influence, 
on  the  sound  one.  In  either  case,  however,  he  con- 
fines himself  to  the  selected  side,  and  any  change 
indicates  an  alteration  in  the  state  of  the  disease. 

Another  class  of  patients  who  prefer  one  side  are 
those  who  have  a  cavity  in  the  lung.  When  this 
cavity  lies  with  its  aperture  below,  the  secretion 
flowing  from  it  enters  healthy  bronchi,  and  by  irri- 
tating them  maintains  a  perpetual  and  most  distress- 
ing cough.  If,  however,  such  a  patient  turns  over, 
so  that  the  cavity  fills  before  its  contents  escape,  a 
period  of  tranquillity  is  obtained,  and  though  the 
cough  eventually  recurs,  a  larger  quantity  of  secretion 
c   ■ 


1 8  Condition  and  Appearance, 

is  promptly  got  rid  of,  and  another  period  of  rest 
secured.  The  recognition  of  this  fact  is  often  of 
service  in  indicating  the  presence  of  a  vomica.  AVhen, 
as  frequently  happens  in  phthisis,  the  secretion  is 
tough  and  scanty,  this  symptom  is  inconspicuous. 

Even  in  health  many  persons  feel  more  comfort- 
able on  one  side  than  on  the  other,  and  when  ill  will 
often  continue  to  prefer  the  accustomed  attitude ; 
hence  the  fact  that  the  patient  is  repeatedly  found  on 
one  side,  although  it  suggests  the  propriety  of  being 
on  the  outlook  for  disease,  does  not  always  indicate  its 
presence. 

In  cases  where  great  demands  are  made  upon  the 
respiratory  system,  and  especially  when  it  fails  to 
respond  fully  to  such  demands,  the  sufferer  can  rarely 
lie  down  in  bed,  but  sits  more  or  less  erect  and 
propped  up  with  pillows.  To  this  condition  the 
name  of  orthopiioea  has  been  given.  It  is  common 
in  advanced  stages  of  heart,  lung,  and  kidney  disease, 
and  its  rationale  is  found  in  the  fact  that  this  attitude 
permits  of  freer  use  of  the  accessory  respiratory 
muscles,  whilst  it  leaves  the  diaphragm  less  impeded 
by  intra-abdominal  pressure,  and  perhaps,  also,  acts 
favourably  on  the  intra-cranial  venous  pressure."^ 
When  abdominal  distension  is  great,  the  sufferer  can- 
not flex  his  thighs  without  raising  the  abdominal 
pressure ;  hence  he  leaves  his  bed  and  sits  well  forward 
in  an  armchair,  resting  his  head  on  a  table  before 
him,  and  bending  his  thighs  as  little  as  possible.  In 
such  cases  the  removal  of  the  ascitic  effusion  may 
afford  unspeakable  relief  to  the  patient. 

In  abdominal  disease,  especially  when  the  peri- 
toneum is  involved,  the  aspect  is  frequently  character- 
istic. The  patient  lies  on  his  back  with  a  rigidity  of 
attitude  and  shallow  respiration  which  betoken  the 
pain  that  any  movement  produces,  whilst  one  or  both 

*  See  Sahli,  "  Kliiiische  Uutersucbungsmethoden,  '  p.  4. 


Attitude  of  Patient.  19 

legs  are  drawn    up,   according    as    the    inflammation 
is  limited  to  one  side  or  has  become  more  general. 

In  colic  and  dysmenorrlioea  there  is  often  great 
restlessness,  which  contrasts  vividly  with  the  fixed 
attitude  of  serious  inflammation.  In  renal  colic  the 
patient  tosses  about  and  tries  one  position  after 
anotlier  in  futile  search  for  a  posture  free  from  pain, 
whilst  the  less  acute  but  more  constant  dragging  pain 
of  renal  calculus  produces  a  drooping  of  the  shoulder 
on  the  aflected  side,  which  is  most  marked  when  the 
patient  is  erect,  but  may  be  present  even  in  bed. 

Patients  who  are  attacked  by  acute  rlieumatism 
have  a  peculiar  aspect  of  helplessness,  the  limbs  lying 
motionless,  and  the  joints  being  swollen,  stiff",  and 
painful. 

Various  diseases  of  the  nervous  system  produce 
characteristic  attitudes  ;  peculiarly  important  is  that 
of  meningitis,  where  the  neck  is  bent  backwards 
so  that  the  head  seems  to  bore  into  the  pillow. 

When  possible,  the  physician  should  not  only 
study  his  patient  in  bed,  but  should  also  see  him 
up  and  walking.  Many  very  characteristic  attitudes, 
which  are  of  the  greatest  value  in  forming  a  diag- 
nosis, can  only  be  observed  when  the  patient  is  in 
the  erect  j^osture.  Thus  the  forward  stoop,  the 
stiff"  neck,  the  tremor,  and  the  fingers  flexed  at  the 
metacarpal  joints  and  working  against  the  thumb  as 
though  engaged  in  making  cigarettes,  are  as  charac- 
teristic of  paralysis  agitans  as  is  the  festinant  gait. 

When  the  patient  is  standing-,  observe  (1)  the 
pose  of  the  head;  (2)  the  set  of  the  shoulders;  (3) 
the  inclination  at  which  the  trunk  is  carried  on  the 
pelvis — thrown  back  in  hypertrophic  muscular  para- 
lysis, in  pregnancy,  and  in  massive  abdominal  tumour, 
often  bent  forward  when  abdominal  pain  is  present ; 
(4)  the  position  of  the  arms  and  hands  ;  (5)  the  out- 
line of  the  lower  limbs. 


20  Condition  and  Appearance. 

When  the  patient  walks,  any  peculiarity  in  his 
g'ait  must  be  observed.  The  more  important  types 
of  gait  are  described  in  Chapter  XI.,  but  the  student 
must  remember  that  alterations  may  be  due  not  only 
to  diseases  of  the  muscular  and  nervous  systems  but 
that  the  pain  of  a  gouty  toe,  or  of  a  blistered  heel,  or 
surgical  conditions  in  the  ankle,  knee,  and  hip  joints, 
likewise  produce  characteristic  effects. 

At  least  a  passing  glance  should  be  bestowed 
on  the  dress.  Apart  from  insanity,  where  the 
patient's  clothing  is  fi-equently  dishevelled  or  gro- 
tesque, the  following  points  should  be  noted  :  (1)  Is 
the  patient  too  stout  for  his  clothes  ?  In  this  case 
various  dodges  have  to  be  adopted  to  get  the  buttons 
to  meet  their  buttonholes. 

(2)  Are  his  boots  slit,  as  one  sees  in  persons  who 
are  suffering  from  gout  or  corns  ?  Are  tbey  loosely 
laced  because  of  oedema  of  the  feet  %  Are  they  unduly 
worn  at  the  toes,  as  in  spastic  paralysis  ? 

(3)  Are  the  clothes  neatly  put  on,  or  are  buttons 
left  unfastened  or  wrongly  fastened,  as  may  be  the 
case  either  from  mental  conditions  or  from  weakness 
which  is  so  great  as  to  render  the  patient  unwilling  to 
make  any  unnecessary  exertion  % 

(4)  Are  there  stains  of  urine  on  the  front  of  the 
trousers ;  and  are  these  stains,  if  present,  streaked 
with  a  deposit  of  glucose  *? 

The  g^eiieral  developiueiit  aiitl  iiutritioii 
of  the  patient  demand  careful  examination.  In 
different  types  of  men  very  considerable  variations 
must  be  looked  for,  and  various  races  differ  greatly  in 
breadth  of  beam.  Age  also  is  a  factor  which  cannot 
be  left  out  of  the  reckoning,  and  a  proportion  between 
height,  girth,  and  weight  that  would  be  natural  enough 
at  fifty  may  be  quite  abnormal  at  twenty-one.  Recog- 
nising, however,  that  variations  must  be  expected  in 
individual  cases,  there  is  still  a  certain  general  ratio 


Development  of  Patient.  21 

between  height,  weight,  and  chest  circumference  which 
has  been  found  to  represent  the  average  of  a  very 
large  number  of  cases,  and  may  therefore  be  taken  as 
a  rough  standard,  any  wide  divergence  from  which 
wouhl  call  for  special  explanation.  The  following 
table  is  one  of  several  that  have  been  compiled  from 
very  extensive  statistics.* 

Heisht. 


ft. 

in 

5 

1 

5 

3 

5 

5 

5 

6 

5 

7 

5 

8 

5 

9 

5 

10 

0 

11 

6 

0 

Limits  of  deviation  in 

SToniial  weight. 

excess  or  defect  of  this 

which 

are  compatible 

■with  good  health. 

lbs. 

lbs. 

120 

-1-    24 

133 

-1-    27 

142 

-i-  28 

145 

+  29 

148 

^   30 

155 

-f   31 

162 

-f  32 

169 

-f   34 

174 

^   35 

179 

+   36 

Various  attempts  have  been  made,  with  partial 
success,  to  produce  a  formula  which  would  enable  the 
weight  to  be  estimated  when  the  height  and  girth  are 
known.     One  of  these,  cited  by  H.  Yierordt,  is  W  = 

-^rjj-  kilograms,  where  W  stands  for  weight,   H   for 

height  in  centimetres,  and  G-  for  girth  in  centimetres. 
If  one  translates  the  metric  into  the  more  usual  British 
system,  and  estimates  the  weight  in  pounds  and  the 
height  and  girth  in  inches,  the  formula  becomes  W  = 

^y-lbs. 

It  is  important  to  compare  the  chest  girth  taken 
at  the  level  of  the  nippiest  with  that  of  the  abdomen. 
If  in  a  man  below  middle  age  the  latter  measurement 
is  the  larger,  it  either  indicates  an  undue  tendency  to 

*  Hutchinson.  f  In  male  subjects. 


22  Condition  and  Appearance. 

fat  formation,  which  may  at  a  later  period  impair  his 
vitality,  or  it  is  due  to  intra-abdominal  disease. 

When  these  measurements  have  been  made,  the 
oiutrition  of  the  patient  is  observed.  Under  this  head 
one  notes  whether  the  patient  is  too  stout,  is  well 
nourished,  or  is  emaciated.  In  health  there  is  a  fair 
quantity  of  subcutaneous  fat,  the  muscles  are  of 
moderate  size  and  firm  texture,  whilst  those  which 
have  been  called  into  special  exercise  in  the  ordinary 
occupation  of  the  individual  under  examination  may 
be  markedly  prominent,  and  the  skin  is  elastic  and 
neither  very  moist  nor  very  dry.  When  nutrition  is 
perverted,  the  muscles  become  flabby,  and  the  sub- 
cutaneous fat  is  increased  so  as  eventually  to  become 
burdensome  to  its  possessor ;  or  emaciation  sets  in, 
owing  to  the  balance  between  ingestion  and  excre- 
tion becoming  deranged,  and  the  waste  of  tissue  ex- 
ceeding its  reparation.  Emaciation  is  thus  an  important 
indication  of  many  diseases,  especially  those  which  are 
accompanied  by  fever. 

In  estimating  the  state  of  nutrition,  the  observer 
will  take  into  account  the  general  build  of  the  patient 
— some  are  naturally  small  and  slight,  others  are  large 
and  raw-boned ;  and  one  also  meets  with  ]3ersons  who, 
though  possessed  of  little  subcutaneous  fat,  have  well- 
nourished  muscles,  whilst  others,  whose  muscles  are 
weak  and  soft,  have  an  abundant  supply  of  fat  in  the 
subcutaneous  tissues. 

Besides  the  nutrition  of  the  patient,  an  attempt 
should  be  made  to  ascertain  his  temperaiiieiit 
and,  if  present,  his  diathesis,  since  this  often  exerts 
a  marked  influence  on  the  course  of  his  illness.  The 
analysis  of  temperament  is  beyond  the  scope  of  this 
work ;  the  senior  student  will  find  valuable  contribu- 
tions to  the  subject  in  Hutchinson's  "  Pedigree  of 
Disease." 

To  the  trained  observer  the  expression   of  the 


Expression  of  the  Eve.  23 

patient  yields  information  of  the  very  highest  im- 
portance, and  amongst  the  factors  which  determine 
expression  the  eye  holds  the  foremost  place. 
Some  patients  cannot  look  their  doctor  in  the  face, 
and  this  tendency  to  avoid  catching  his  eye  is  im- 
portant, both  as  indicating  a  probability  that  the 
information  they  are  about  to  give  lacks  truthfulness, 
and  that  they  are  not  to  be  trusted  to  obey  the  in- 
structions which  they  receive.  Sometimes  the  eyes 
are  restless,  following  every  movement  of  the  attend- 
ant, as  often  occurs  in  phthisis  ;  at  other  times  they 
stare  vacantly  into  space,  regardless  of  all  that  is 
passing  around  them,  a  condition  well  seen  when  the 
consciousness  is  growing  dull.  In  exophthalmos  the 
eyes  are  prominent,  and  show  a  ring  of  sclerotic  above 
the  cornea  ;  or  the  prominence  may  be  due  to  a  high 
degree  of  myopia.  In  wasting  disease  or  in  profound 
collapse,  such  as  is  found  in  cholera,  the  sunken  eyes 
and  half-closed  eyelids  cannot  fail  to  command  atten- 
tion. There  are  racial  differences  in  the  "  set "  and 
obliquity  of  the  eyes,  and  by  noting  this  feature  some- 
thing may  at  times  be  learned  either  of  the  heredity  of 
a  patient  or  of  the  tendency  to  reversion  towards  a 
lower  type.  The  arch  of  the  eyebrows  may  give  a 
hint,  where  it  is  either  excessive  or  too  slight,  of 
a  proclivity  to  tubercular  disease,  and  an  even  closer 
connection  seems  to  exist  between  the  strumous 
tendency  and  long  dark  eyelashes,  coupled  with  sin- 
gularly clear  sclerotics.  More  detailed  reference  is 
made  in  a  subsequent  chapter  to  important  abnormali- 
ties in  the  different  structures  of  the  eye,  where  the 
student  will  learn  how  the  conjunctiva  and  sclerotic 
tell  of  tubercle  and  Bright's  disease,  of  ansemia  and 
rheumatism,  of  jaundice  and  of  intemperance  ;  and 
how  the  cornea  foretells  an  early  onset  of  senile 
changes  in  other  organs  by  the  appearance  of  an 
arcus   senilis,   or  reveals  the  ravages  of  syphilis  and 


24       "        Condition  and  Appearance. 

struma  ;  how  the  size  and  mobility  of  the  pupils  indi- 
cate the  existence  of  disease  in  the  nervous  system, 
or  the  presence  of  aneurysm,  or  it  may  be  only  of 
synechise  from  an  old  iritis  ;  how  the  iris  may  con- 
tain a  tubercular  nodule,  or  be  muddy  and  discoloured 
from  iritis;  and  how  in  females  it  often  serves  as  an 
index  to  the  nervous  energy  of  the  reproductive  system, 
flashing  and  glittering  incessantly  where  ovarian  irri- 
tation is  present,  or  dull  and  dead  where  uterine  dis- 
charge is  too  profuse,  or  where  there  has  been  sexual 
excess."^ 

The  lower  eyelids  are  puffy  and  cedematous, 
especially  in  the  morning,  when  the  patient  is  sufiering 
from  Bright's  disease  ;  they  maj^  be  swollen  and  in- 
flamed as  the  result  of  bug  bites.  People  look  "  dark 
under  the  eyes  "  when  their  digestion  is  out  of  order, 
or  when  fatigued,  especially  from  Avant  of  sleep  ;  often 
women  are  darker  under  the  eyes  during  menstruation 
than  at  other  times. 

The  nose  has  a  sunken  bridge  in  congenital 
syphilis  ;  the  tip  is  red  in  some  cases  of  mitral  regur- 
gitation, in  habitual  drunkards,  in  females  with  chronic 
indigestion, t  and  sometimes  in  purely  local  conditions. 
Undue  mobility  of  the  alse  nasi  may  be  due  to  neurosis, 
or  it  may  indicate  obstruction  to  inspiration,  and  is  in 
this  respect  very  important  to  look  for  in  infants. 

The  lips  are  j^ale  in  chlorosis  and  other  forms  of 
ansemia  ;  livid  and  blue  in  heart  disease  when  compen- 
sation fails.  A  thick,  short,  and  coarse-looking  upper 
lip  is  often  found  in  association  with  a  phthisical 
tendency,  whilst  thin,  mobile  lips  occur  in  persons  of 
a  neurotic  temperament,  and  especially  in  female 
invalids  whose  constitutions  are  naturally  weak,  and 
who  have  not,  nor  can  ever  hope  to  possess,  a  large 
stock  of  vitality.  Herpes  on  the  lip  is  very  often 
associated  with  intrathoracic  inflammation,  and  when 

*  Fothergill,  "Practitioner's  Handbook,"  p.  46G.     f  I^i'^- 


General  Expression.  25 

it  occurs  the  presence  of  pneumonia  should  be  suspected 
and  examined  for. 

The  ears  are  often  ill-developed  in  idiots,  and 
sometimes  in  the  insane  develop  hsematomata.  Of 
greater  frequency  is  the  occurrence  of  tophaceous 
nodules  in  persons  of  gouty  habit. 

The  cheeks  give  valuable  information  regardinsj 
the  patient's  health.  In  anaemia  and  aortic  disease 
they  are  pale ;  in  hectic  fever  there  is  a  bright  cir- 
cumscribed blush  over  the  malar  bones  ;  in  the  capil- 
lary engorgement  of  jDlethora  they  are  ruddy  and 
high-coloured,  as  they  also  are  in  many  persons  who 
lead  an  open-air  life,  exposed  to  all  weathers ;  in  heart 
disease  they  are  also  high-coloured  when  back  pressure 
has  begun  to  tell  on  the  systemic  circulation,  but  the 
colour  is  of  a  bluish  and  cyanotic  tint,  which  cannot 
be  mistaken  for  the  rubicund  cheeks  of  plethora.  In 
unilateral  chest  inflammations,  and  particularly  in 
pneumonia,  the  cheek  corresponding  to  the  affected 
lung  may  be  flushed,  but  if  the  patient  has  been  lying 
for  some  time  on  one  side  there  is  often  a  diflerence 
between  the  two  cheeks,  resulting  from  the  pressure 
of  the  lower  one  upon  the  pillow,  quite  apart  from 
the  presence  of  disease. 

The  form  of  the  crauiiiiu  may  also  indicate 
points  of  importance,  to  which  reference  is  made  in 
Chapter  IX. 

In  addition  to  the  appearance  of  individual 
features,  the  general  expression  of  the  patient 
must  be  noted.  Is  it  animated,  apathetic,  or  has  it 
the  absolute  vacancy  of  unconsciousness  \  Are  there 
wrinkles  on  the  face,  or  is  it  smooth ;  or  is  one  side 
smooth  and  the  other  wrinkled,  as  one  sees  it  in  uni- 
lateral paralysis  of  the  seventh  nerve  %  Is  the  mouth 
drawn  over  to  one  side,  and  is  there  any  other  lack  of 
symmetry  between  the  two  halves  ?  The  expression 
may   be    characteristic    of  pain,  or  there    may  be    a 


2  6  Condition  and  Appearance. 

placidity  resting  on  the  features  which  gainsays  the 
assertion  of  a  patient  that  his  agony  is  most  severe, 
A  look  of  anxiety  on  a  patient's  face  often  presages 
serious  illness  at  a  time  prior  to  the  appearance  of  any 
other  signs  or  symptoms  which  would  suggest  the 
gravity  of  the  situation.  When  pain  is  present,  the 
various  features  are  differently  affected,  according  to 
its  situation.  Pain  in  the  head,  whether  simple  head- 
ache or  of  organic  origin,  causes  the  sufferer  to  frown; 
pain  in  the  chest  which  interferes  with  respiration 
accentuates  the  nasal  furrows,  whilst  abdominal 
pain  is  often  characterised  by  a  drawing  of  the 
angles  of  the  mouth.  These  signs  are  of  peculiar 
importance  in  the  case  of  children  who  cannot 
describe  their  sufferings."^  The  physiognomy  of  in- 
sanity is  often  highly  characteristic,  but  descriptions 
of  it  must  be  obtained  from  special  text-books.  In 
serious  illness  the  nose  often  looks  pinched,  the  eyes 
look  sunken  and  lustreless,  and  the  chin  and  malar 
bones  sharp  and  prominent,  owing  to  the  loss  of  tone 
which  the  soft  tissues  have  undergone. 

Several  types  of  expression  have  received  special 
names.  Of  these  the  most  important  are  the  facies 
Hippocratica  and  the  typhoid  facies.  f 

In  the  facies  Hippocratica  the  skin  is  livid 
or  pale,  and  opaque,  the  eyes  are  dull  and  sunken 
but  remain  open,  the  nose  is  sharpened,  the  temples 
are  hollow,  the  chin  is  sharp,  the  mouth  is  open 
through  dropping  of  the  lower  jaw,  the  ears  are  cold 
and  shrunken,  and  the  cheeks  drawn  in.  When  this 
facies  is  associated  with  abdominal  disease  there  is 
a  red  or  livid  ring  around  the  eyes.     The  Hippocratic 

*  A  most  valuable  contribution  to  the  explanation  of  these 
special  appearances  will  be  found  in  Prof.  O.  Soltmann's 
"Ueber  das  Mienen-  und  Geberdenspiel  kranker  Kinder,"  in  the 
"  Jahrbuch  f.  Kinderheilk, "  Bd.  xxvi.,  p.  206. 

t  0/ Fothergill's  "  Phj'siological  Factor." 


State  of  the  Skin.  27 

facies  is  a  presage  of  impending  dissolution.  The 
typhoid  facies  is  characterised  by  dull,  lustreless 
eyes,  tremor  of  the  lips  (with  muttering  delirium), 
and  a  blank,  expressionless  countenance.  Associated 
with  this  are  found  a  brown  dry  tongue,  a  rapid 
pulse,  a  tendency  to  sink  low  in  the  bed,  twitching 
of  the  tendons  {suhsultus  tendimnn),  and  a  constant 
purposeless  picking  of  the  bedclothes. 

The  state  of  the  skin  where  it  is  exposed 
must  be  carefully  investigated.  In  the  face  we 
notice  especially  the  complexion.  This  is  depend- 
ent on  two  factors — the  colour  and  the  transparency 
of  the  skin.  The  most  important  abnormalities  are 
pallor,  yellowness,  bronzing,  an  earthy  tint,  and  a 
dusky  bluish  red  hue.  Pallor  occurs  in  various 
anaemic  states,  and  also  when  the  heart's  action  is 
greatly  enfeebled,  as  in  fainting  or  severe  nausea. 
Yellowness  may  be  due  to  pernicious  anaemia,  when 
the  tint  is  pale  lemon  yellow,  which  contrasts  with 
the  whiteness  of  the  sclerotics  ;  or  to  jaundice,  when  the 
skin  may  be  only  faintly  discoloured,  or  may  be  of  a 
dark  yellow  colour  with  excoriations  from  the  scratching 
that  results  from  the  intense  itchiness  which  the  bile 
acids  evoke.  In  jaundice  the  conjunctiva  and  mucous 
membranes  share  in  the  coloration.  Bronzing 
is  found  in  Addison's  disease,  and  affects  both  the 
skin  and  the  inside  of  the  mouth.  An  earthy  tint 
is  common  in  states  of  serious  ill-health.  It  some- 
times indicates  a  malarial  history;  in  other  instances 
it  is  the  result  of  syphilis  or  of  cancer ;  and  in  yet 
others  it  can  be  traced  to  an  anaemic  condition  main- 
tained by  continual  small  losses  of  blood,  such  as 
bleeding  piles  may  involve.  This  tint  is  partly  due 
to  the  altered  state  of  the  blood,  partly  to  abnormal 
opacity  of  the  skin.  The  dusky  tint  of  embarrassed 
breathing  and  of  advanced  heart  disease  does  not 
demand  further  notice  here. 


28  Condition  and  Appearaace. 

It  is  also  important  to  search  for  cutaiieoHS 
eruptions,  some  of  which — measles  and  syphilitic 
rashes,  for  example — frequently  appear  first  about 
the  roots  of  the  hair,  whilst  others  have  equally  dis- 
tinctive situations.  Ulcers  and  scars  should  also  be 
looked  for.  The  colour  and  nutrition  of  the  hair,  and 
the  dryness  or  moisture  of  the  skin,  must  be  noted; 
and  if  perspiration  is  present,  its  amount  and 
situation.  The  perspiring  brow  of  a  rachitic  child 
is  very  characteristic. 

Reference  has  already  been  made  to  the  paiiiii- 
culus  adiposiis ;  but  in  addition  to  the  presence 
or  absence  of  fat,  morbid  conditions  may  lead  to 
abnormal  states  of  the  cellular  tissues.  The  chief 
of  these  are  the  presence  of  fluid  or  of  air,  the  former 
being  by  far  the  commonest.  When  fluid  is  present, 
the  condition  is  known  as  dropsy,  and  there  are 
two  varieties  of  this,  which  are  sometimes  de- 
scribed as  ''hydrasmic"  and  "passive."  In  hydrtemic 
dropsy,  typical  examples  of  which  occur  in  sufferers 
from  J3rio[ht's  disease,  the  transudation  does  not  first 
show  itself  in  the  most  dependent  parts  ot  the 
body,  but  in  other  sites  where  laxity  of  the  tissues 
favours  its  accumulation.  Thus  in  chronic  nephritis 
an  early  symptom  is  the  oedema  of  the  face,  especially 
below  the  eyes,  which  comes  and  goes,  being  most 
noticeable  when  the  patient  first  rises  in  the  morning. 
In  passive  dropsy,  however,  which  is  typically  present 
in  those  cases  where  pulmonary  or  cardiac  disease 
produces  a  backward  pressure  in  the  veins,  the 
swelling  first  appears  at  the  ankles  and  over  the 
dorsum  of  the  foot,  and  only  gradually  mounts  to 
the  legs,  thighs,  and  trunk.  When  the  venous 
obstruction  is  local,  the  dropsy  is  confined  to  the 
parts  from  which  the  return  of  blood  is  impeded. 
In  this  way  one  finds  ascites  resulting  from  cirrhosis 
of  the  liver,  or  oedema  of  an  arm  when  the  axillary 


Evidence  of  the  Hands.  29 

glands  are  cancerous  and  constrict  the  axillary 
vein.  (Edema  of  the  whole  upper  part  of  the  body 
may  result  from  intrathoracic  tumours ;  the  M^riter 
has  seen  it  follow  compression  of  the  superior  vena 
cava  by  an  aneurysm.  Dropsy  may  be  recognised 
by  the  pallid  and  glossy  appearance  of  the  skin  over 
the  swollen  part,  by  its  doughy  feel,  and  by  the 
fact  that  it  pits  on  pressure, 

Localised  cedeina  may  be  due  to  nervous 
causes,  and  is  found  in  certain  of  the  angioneurotic 
group  of  diseases. 

8ubcittaiieoiis  eiiipliyseiiia  is  not  common, 
but  when  present  it  can  be  readily  recognised  by 
the  crackling  sensation  which  is  detected  on  pinching 
the  part  affected. 

The  hands  of  the  patient  merit  careful  observa- 
tion. Notice  the  strength  of  his  grip  as  he  shakes 
hands;  this  often  indicates  improvement  or  the 
reverse  with  considerable  accuracy.  Their  general 
shape  should  then  be  noted.  Are  they  stunted,  as 
in  congenital  cretinism,  or  "  spade-like,"  as  in 
myxcedema  ;  are  the  joints  large,  as  occurs  in  rickets 
and  in  persons  of  strumous  diathesis'?  Are  they 
deformed  as  well,  as  occurs  in  rheumatoid  arthritis, 
or  swollen  and  painful,  as  in  acute  rheumatism  % 
Sometimes  what  looks  like  enlargement  of  the  joints 
is  really  due  to  wasting  of  the  surrounding  tissues. 
When  the  patient  is  gouty,  the  finger  joints  are 
often  implicated,  and  tophaceous  nodules,  known  as 
Heberdeii's  kiiotos,  are  formed.  These  must  not 
be  confused  with  Haygarth's  nodosities,  which 
are  fibrous  thickenings  found  in  cases  of  rheumatism. 
Gout  sometimes  shows  itself  by  jDroducing  a  contrac- 
tion of  the  palmar  fascia  that  prevents  extension 
of  the  fingers.  In  nerve  disease  the  skin  of  the 
hand  may  undergo  trophic  chang-es,  becoming 
thin  and  glossy ;  or  the   vessels  may  be   influenced 


30  Condition  and  Appearance. 

by  vasomotor  disorders,  and  lead  to  redness  or  to 
a  pallid  and  dead-looking  state  of  the  fingers.  Nerve 
diseases  also  produce  very  characteristic  movements 
or  attitudes  of  the  hand,  as  may  be  seen  in  athetosis 
and  lead  palsy.  In  ulnar  paralysis  the  hand  become:^} 
deformed  by  over-extension  of  the  first  phalanges, 
combined  with  excessive  flexion  of  the  rest,  so  that 
a  claw-like  attitude  is  produced.  This  is  known  as 
the  '^  main  en  grille."  When  the  muscles  of  the 
thenar  and  hypothenar  eminences  have  undergone 
atrophy  the  hand  becomes  flattened,  and  thus  some- 
what resembles  that  of  an  ape.  In  acromegaly  and  in 
pulmonary  osteoarthropathy  there  are  very  character- 
istic enlargements  of  the  hands,  which  present  a 
singularly  massive  appearance.  The  fingers  become 
clubbed  under  conditions  which  produce  chronic 
congestion  of  the  peripheral  veins,  chief  amongst  such 
conditions  being  respiratory  or  cardiac  embarrassment. 
Where  the  congestion  is  marked  the  finger  tips  are 
blue  and  cold,  and  the  nails  are  much  curved  longi- 
tudinally. The  nails  exhibit  longitudinal  grooves  in 
gouty  persons,  in  whom  also  they  are  often  singularly 
hard  and  brittle;  whilst  a  transverse  furrow  is  the 
record  of  some  former  interference  with  the  nail's 
nutrition,  and  in  the  absence  of  a  local  cause  points 
to  some  severe  constitutional  illness.  Many  persons, 
especially  those  of  the  so-called  lymphatic  tempera- 
ment, have  moist  and  clammy  hands.  These  in 
women  frequently  indicate  excessive  leucorrhoeal  loss, 
and  so  aid  in  directing  inquiry  towards  this  subject. 
Even  when  the  hand  is  not  moist  when  the  patient  is 
seen,  the  fact  that  the  colour  has  been  sweated  out  of 
the  palm  of  the  glove  may  show  that  the  tendency 
exists."^  In  infants  the  movements  or  position  of 
the  hands  and  fingers  will  often  direct  an  acute 
observer  to  the  seat  of  disease. 

*  Fothergill. 


State  of  the  Neck.  31 

The  neck  should  always  be  inspected,  and  special 
note  taken  of  any  of  the  conditions  about  to  be 
described. 

1.  The   state   of   the    lymphatic    glands.— In 

syphilis  the  glands  under  the  upper  part  of  the 
trapezius  are  A'ery  frequently  enlarged.  In  septic 
ear  diseases  the  glands  below  the  ear  can  often  be 
readily  felt.  Where  there  are  carious  teeth,  and 
where  there  is  iDalignant  disease  in  the  mouth, 
enlarged  glands  can  usually  be  detected  near  the 
angles  of  the  jaw.  In  scrofulous  persons  enlarged 
tubercular  glands  occur  in  groups  or  in  long  chains 
beside  the  sternomastoid,  and  scars  will  mark  the 
points  where  they  have  suppurated.  In  lymphade- 
noma  the  glands  are  enlarged  and  firmly  matted 
together.  If  enlarged  glands  are  found  either  in  the 
neck  or  elsewhere,  it  is  important  to  observe  whether 
they  remain  firm  and  distinct,  or  become  fused 
together,  or  whether  fluctuation  can  be  detected. 

2.  The  thyroid  gland.— The  existence  of  any 
swelliDg  of  this  gland  is  important,  and  its  effect  on 
the  patient's  respiration  should  be  studied.  Some- 
times such  enlargements  exercise  considerable  pressure 
on  the  trachea ;  at  other  times,  particularly  if  the 
disease  be  malignant,  the  recurrent  laryngeal  nerves 
may  become  implicated.  In  cases  where  there  is 
difficulty  in  determining  whether  a  tumour  is  con- 
nected with  the  thyroid,  much  assistance  may  be 
obtained  from  the  fact  that  the  gland  and  any  tumour 
which  is  connected  with  it  move  up  and  down  with 
the  larynx  during  deglutition. 

3.  Unusnal  prominence  of  any  muscle 
or  group  of  muscles  in  the  neck  should  be  described. 
Such  prominence  may  be  bilateral,  as  of  both  sterno- 
raastoids  in  emphysema,  or  unilateral,  as  in  tonic  wry 
neck.  A  congenital  sternomastoid  tumour  may  be 
present,    and,  if    unrecognised,    may    lead    to    much 


32  Condition  and  Appearance. 

perplexity ;  whilst  various  cysts,  cold  abscesses,  or 
developmental  abnormalities  may  be  encountered. 
Their  recognition,  however,  is  rather  a  question  for 
surgical  diagnosis. 

4.  Movements  of  the  l£iryii§^eal  box  are 
sometimes  conspicuous,  and  may  call  for  explanation. 

5.  Rig-idity  of  the  neck  may  be  due  to  inflam- 
mation, to  rheumatism,  to  disease  of  the  spinal  column, 
or  to  various  nervous  diseases,  whilst  spasmodic  move- 
ments occur  in  clonic  torticollis. 

6.  Any  bulg^ing^  of  the  apices  of  the  liiug^s 
during  a  fit  of  coughing,  or  pulsations  seen  in  the 
vessels,  must  be  recorded,  nor  must  the  existence  of 
aneurysm  be  overlooked. 

7.  Boils  and  carbuncles  are  very  frequently 
situated  on  the  back  of  the  neck.  As  they  are  not 
infrequently  present  in  cases  of  diabetes,  they  should 
direct  the  observer's  inquiries  to  the  urinary  system, 
and  sugar  should  be  tested  for. 

8.  Finally,  with  respect  to  the  general  shape 
of  the  neck,  it  should  be  noted  whether  it  is  short 
and  thick,  or  long  and  smooth,  or  "  scraggy,"  or  pro- 
jecting forwards  with  a  prominent  larynx.  The  last' 
form  is  common  in  persons  with  phthinoid  chests. 

The  character  of  a  patient's  I'espiration  is  often 
of  great  service  in  reaching  a  diagnosis  and  a  prog- 
nosis."^ Where  the  respiratory  passages  are  ohstriicted 
the  normal  quiet  respiratory  sound  is  replaced  by 
more  or  less  noisy  breathing.  When  the  obstruction 
occurs  in  the  nose  either  from  mucus  in  the  meatus 
or  from  thickening  of  the  mucosa  which  covers  the 
turbinated  bones,  or  from  paralysis  of  the  ake  nasi, 
the  breathing  is  sniffing  or  bubbling  in  character. 
When  the  soft  palate  is  relaxed,  and  especially  when 

■^■^  Much  of  what  follows  is  based  on  Dr.  Wyllie's  papers  on 
"  Extra- Auscultation,"  and  his  classification  is  in  great  measure 
adopted. 


Character  of  Respiratio^n.  33 

it  is  paralysed,  it  prevents  tlie  free  passage  of  air 
between  the  mouth  and  thorax,  and  produces  a  snoring 
or  stertorous  sound.  When  the  rima  glottidis  is 
obstructed  from  any  cause,  such  as  spasm  or  paralysis 
of  the  vocal  cords  or  oedema  of  the  larynx,  stridulous 
breathing  results.  If  a  polypus  or  other  tumour  lie 
between  the  cords,  there  may  either  be  stridor  or 
simply  noisy  breathing.  The  trachea  may  have  its 
airway  narrowed  by  pressure  from  the  outside,  as  in 
cases  of  tumour  and  especially  of  aneurysm,  when 
the  breathing  becomes  growling  ;  or  mucus  may  ob- 
struct the  lumen,  producing  a  rattling  sound.  The 
"death-rattle,"  which  occurs  when  weakness  and 
insensitiveness  combine  to  prevent  any  effort  at 
expectoration,  is  a  typical  example  of  the  condition. 
Obstruction  in  the  bronchi  gives  rise  to  wheezing  and 
crackling  sounds.  Sometimes  the  respiration  is  sigh- 
ing; Gairdner  is  inclined  to  think  that  this  may  indi- 
cate fatty  degeneration  or  slight  dilatation  of  the 
heart.  An  important  division  of  dyspnoeic  conditions 
may  be  made  according  as  the  difficulty  in  respiration 
is  felt  during  the  inspiratory  or  the  expiratory  period. 
Most  cases  of  obstruction  of  the  air-passages  are 
characterised  by  inspiratory  dyspncea,  whilst 
many  of  the  pulmonary  causes  of  dyspncea  produce 
expiratory  trouble.  As  a  common  example  of  the 
latter  one  may  cite  the  prolonged  expiration  of  a  case 
of  bronchitis  with  emphysema.  The  breathing  may 
be  characteristic  of  diseases  quite  distinct  from  those 
of  the  respiratory  system.  Examples  of  this  are 
found  in  the  stertorous  breathing  of  apoplexy,  the 
hissing  expiration  of  uraemia,  and  the  dyspncea  or 
"  air- hunger  "*  of  commencing  diabetic  coma,  which 
affects  both  inspiration  and  expiration. 

If  eotigh  is  present,  its  character  must  be  most 
carefully   noted.     The   first  thing   to   observe  in  this 

*  Kiissmaul. 
D 


34  Condition  and  Appearance. 

connection  is  whether  the  cough  consists  of  inde- 
pendent explosive  expirations,  or  is  paroxysmal  in 
character.  The  former  occurs  in  early  phthisis,  in 
granular  pharyngitis,  and  in  some  forms  of  nervous 
irritation ;  the  latter  is  often  found  in  severe  bron- 
chitis, and  is  very  typical  in  pertussis.  One  should 
also  notice  whether  the  cough  induces  pain  or  nausea, 
and  whether  its  tone  is  resonant,  or  suppressed,  or 
husky.  In  common  colds  the  cough  is  at  first  short 
and  dry,  but  as  the  quantity  of  secretion  increases, 
the  type  becomes  more  paroxysmal,  and  the  fit  of 
coughing  continues  till  the  mucus  is  expectorated. 
In  bronchitis  the  condition  resembles  that  found  in 
the  last  affection,  but  the  paroxysms  are  more  severe, 
and  wheezing  is  often  present.  When  due  to  early 
phthisis,  the  cough  is  frequent,  short,  and  sharp,  and 
is  described  as  dry  because  there  is  no  rattling  of 
mucus  associated  with  it.  Later  in  the  disease, 
when  the  caseous  masses  are  breaking  down,  secre- 
tion is  much  more  copious,  and  the  cough  becomes 
moist  and  paroxysmal.  In  severe  cases  actual  vomit- 
ing may  be  induced.  A  nervous  cough  generally 
has  the  character  of  single,  short,  dry  explosions, 
repeated  at  intervals,  and  a  similar  type  is  produced 
by  irritation  of  the  peripheral  nerves,  whether  the 
source  of  the  irritation  be  found  in  a  disordered 
stomach  or  threadworms  in  the  rectum,  or  be  due 
to  disease  in  the  ear  or  to  the  discomforts  of  teeth- 
ing, or  take  origin  in  the  nerves  of  the  jDregnant 
uterus.  Local  conditions  in  the  throat  may  be  the 
cause  of  most  troublesome  and  persistent  cough- 
ing, and  a  careful  observer  will  not  fail  to  look  for 
granular  pharyngitis  when  the  patient  complains  of 
constant  hawking,  or  for  a  relaxed  and  trailing  uvula 
more  particularly  when  the  cough  starts  the  instant 
the  patient  lies  down. 

In  pleurisy,  2)i^^umonia  (associated  as  it  often  is 


Varieties  of  Cough. 


35 


with  more  or  less  pleurisy),  and  in  'pleurodynia^  the 
cough  consists  of  solitary  dry,  hacking,  expulsive  efforts, 
suppressed  as  much  as  possible  to  prevent  unneces- 
sary pain,  but  repeated  frequently.  In  laryngitis  and 
crouj)  the  cough  may  be  simply  noisy,  but  more  often 
is  either  husky  or  stridulous.  When  the  lumen  of 
the  trachea  is  encroached  upon  by  a  mediastinal 
tumour  or  an  aneurysm  there  is  generally  a  very 
resonant,  brassy  cough,  aptly  compared  to  the  cry  of  a 
gander.  When  once  heard,  this  is  almost  sufficient  to 
clinch  the  diagnosis  without  further  examination. 

In  hysteria  the  cough  is  often  loud  and  barking, 
and  gives  the  impression  of  being  produced  with 
the  ^^.ew  of  attracting  attention.  Such  a  cough  is 
sometimes  associated  with  hysterical  aphonia.  Per- 
tussis, when  it  is  fully  developed,  is  distinguished 
by  a  most  characteristic  cough.  There  is  tirst  a  long- 
drawn,  almost  stridulous  inspiration,  then  a  series 
of  short,  sharp,  expiratory  coughs,  which  follow  each 
other  with  extreme  rapidity.  The  face  turns  dark 
and  the  veins  grow  prominent,  the  child  clings  firmly 
to  any  support  it  can  find,  so  as  to  give  full  play 
to  the  accessory  muscles  of  respiration,  and  when  at 
last  the  fit  of  coughing  ends  it  is  followed  by  a 
long-drawn  whooping  inspiration.  The  severity  of 
the  paroxysm  induces  vomiting,  and  sometimes  causes 
evacuation  of  the  bladder  and  bowel. 

Hii^coug-li,  which  results  from  spasmodic  con- 
traction of  the  diaphragm,  is  a  common  enough  dis- 
order. It  may  be  due  to  trivial  causes,  such  as  an 
attack  of  indigestion  ;  but  it  also  occurs,  and  that 
most  persistently,  in  many  serious  illnesses,  when  the 
symptom  may  become  one  of  considerable  gravity. 
Thus,  if  it  be  met  with  in  a  patient  whose  kidneys  are 
affected,  and  especially  if  the  occurrence  in  such  a  case 
follow  the  passage  of  instruments  to  relieve  stricture, 
there  is  gi'ound  for  serious  apprehension  as  to  the  issue. 


;^6  Condition  and  Appearance, 

The  voice,  as  well  as  the  cough,  should  be  studied. 
The  chief  points  to  observe  are  its  strength, 
whether  it  is  clear  or  husky,  or  whether  aphonia 
exists.  The  voice  may  be  nasal  either  through  habit 
or  in  consequence  of  obstruction  in  the  upper  airways. 
A  distinction  should  be  made  between  open  and 
stopped  nasal  tones,  the  former  resembling  the  sound 
produced  when  the  mouth  is  kept  shut  during  phona- 
tion,  the  latter  that  heard  when  one  speaks  whilst 
holding  the  nose. 

Temperature. — The  hand  laid  upon  the  skin 
gives  a  certain  amount  of  information  as  to  the 
temperature,  especially  if  there  be  no  perspiration  ; 
but  a  far  more  accurate  guide  is  found  in  the  ther- 
mometer, whose  use  should  never  be  omitted."^  In 
taking  the  temperature  the  following  practical 
points  must  be  attended  to  :— 

1.  The  thermometer  must  be  accurate  and  of  good 
quality.  To  insure  accuracy,  it  should  be  compared 
with  a  standard  instrument.  In  Britain  this  is 
done  at  Kew,  and  certificates  are  issued  which  state 
the  error  of  each  individual  instrument.  In  process 
of  time,  however,  and  particularly  if  the  thermometer 
has  been  recently  made,  molecular  changes  occur  in 
the  glass  which  tend  to  make  the  reading  too  high. 
Such  changes  are  slight,  and  seldom  attain  a  value  of 
any  clinical  importance,  though  if  great  accuracy 
is  necessary  a  fresh  comparison  should  be  made  every 
two  or  three  years.  Also,  if  the  bulb  of  the  thermo- 
meter be  made  too  thin  the  glass  will  yield  to  pressure, 
and  the  patient  may  either  purposely  or  accidentally 
compress  it  so  much  as  to  make  the  mercury  reach 
to  four  or  six  degrees  above  the  actual  temperature. 

*  Just  because  the  hand  takes  account  of  moisture  as  well 
as  of  the  actual  temperature,  it  may  convey  information  which 
the  thermometer  fails  to  impart— c.^.  the  "pungent"  dry  heat  of 
early  pneumonia  is  most  eharacteristic. 


Taking  Temperature.  37 

2.  The  thermometer  must  be  kept  in  position  long 
enough  to  allow  the  mercury  to  reach  the  body  tem- 
perature. Generally  it  is  well  to  exceed  the  period 
which  the  instrument  professes  to  require. 

3.  In  adults  the  temperature  is  taken  in  the 
mouth  or  in  the  axilla;  in  young  children  the  ther- 
mometer should  be  placed  in  the  fold  of  the  groin, 
and  the  thigh  flexed  on  the  abdomen,  or  it  may 
be  inserted  into  the  rectum.  The  temperature  of 
the  mouth  and  rectum  is  generally  at  least  half  a 
degree  higher  than  that  of  the  groin  or  axilla,  but  in 
old  people  the  mouth  temperature  is  often  too  low, 
and  less  trustworthy  than  that  of  the  axilla.  When 
taken  in  the  latter  situation,  care  must  be  exer- 
cised to  keep  the  part  as  free  as  possible  from 
perspiration,  both  during  the  observation  and  for  a 
few  minutes  before  it.  Moreover,  the  arm  should 
be  drawn  to  the  side  for  a  short  time  before  the 
thermometer  is  inserted,  that  the  skin  may  not  have 
been  chilled  by  exposure  to  the  air. 

4.  Before  inserting  the  thermometer,  make  an 
invariable  rule  of  washing  it  in  lotion  or  in  cold 
water,  and  see  that  the  mercury  is  well  shaken  down ; 
wash  it  again  before  replacing  it  in  its  case.  In 
Great  Britain  the  Fahrenheit  scale  is  used ;  on  the 
Continent  the  Centigrade.* 

The  temperature  should  he  taken  at  fixed  times 
twice  daily  when  possible,  and  at  shorter  intervals 
when  fever  fluctuates  or  runs  high.  Times  that 
are  convenient  and  that  fairly  represent  the  daily 
conditions,  are  at  9  a.m.  and  7  p.m.  In  health 
the  temperature  has  a  daily  range  of  from  one  to  two 
degrees  Fahrenheit,  being  lowest  in  the  small  hours 
of  the  morning,  and  gradually  rising  to  attain  its 
principal  maximum  somewhere  about  five  or  six  p.m. 
Age  exercises  a  rather  marked  influence  on  the 
*  For  a  comparison  of  the  two  scales  see  Appendix,  4. 


38  Condition  and  Appearance. 

temperature.  In  children  it  varies  greatly  with  their 
time  of  life,  and  trivial  causes  produce  great  fluctua- 
tions. On  the  average,  it  is  about  half  a  degree 
higher  than  in  adults.  In  the  very  old  it  is  also 
slightly  higher  than  in  middle  life  unless  the  circula- 
tion is  weak,  when  the  temperature  may  be  con- 
siderably lower. 

In  diseased  conditions  marked  deviations  from 
the  normal  temperature  are  often  present.  The 
following  terms  are  applied  by  Wunderlich  to  such 
variations  : — 

(a)  Temperatures  much  below  normal  (collapse 
temperatures) — below  96-8°. 

1.  Deep  fatal  collapse  :  below  92-3°. 

2.  Algid  collapse,  not  necessarily  fatal :  92'3°-95°. 

3.  Moderate  collapse  :  95°-96-8°. 
(6)  Temperatures  near  the  normal. 

1.  Subnormal  :  96-8°-97-8°. 

2.  Normal:  97-8°-99-5°. 

3.  Subfebrile  :  99-5°-100-4°. 
(c)  Febrile  temperatures. 

1.  Slightly  febrile  :  100-4°-101-3°. 

2.  Moderately  febrile  :  101-3°-102-2°  morning ;  to 
1031°  evening. 

3.  Decidedly  febrile :  103-1°,  morning  ;  105° 
evening. 

4.  Highly  febrile  :  above  103*1°  morning  to  above 
105°  evening. 

{d)  Hyperpyretic  temperatures  :  above  107°. 

By  consecutive  observations,  taken  at  suitable 
intervals,  it  is  easy  to  determine  whether  an  abnormal 
temperature  is  constantl}^  present  or  only  occurs 
at  intervals.  When  the  temperature  rises  quickly, 
the  patient  feels  chilly  in  consequence  of  the  incom- 
plete response  of  the  vasomotor  mechanism  to  the 
new  conditions,  and  in  marked  cases  rigors  occur. 
If,    however,    the  temperature  remains  continuously 


Abnormal   Tempera tures. 


39 


high,  the  rigor  gives  place  to  a  feeling  of  heat,  coupled 
with  thirst,  headache,  and  a  rapid  pulse.  This  is 
known  as  pyrexia,  or  fever.  If  after  fever  the 
temperature  falls  rapidly,  or  if  during  the  fever  the 
extremities    are    chilled,     the    patient    suffers    from 


lUIIUUIIIIMII 


Fig.  1.— Remittent  fever  (hectie).    Case  of  phthisis.     (After  Finlaysoa.) 

collapse,  when  the  pulse  is  small,  the  features  are 
pinched,  the  skin  is  moist  with  a  clammy  sweat,  and 
the  patient  suffers  from  a  sinkirg  sensation  and  from 
nausea. 

There  are  three  principal  types  of  fever — the 
continued,  the  remittent,  and  the  intermittent. 
When  fever  does  not  fluctuate  more  than  about  a 
degree  and  a  half  (Fahrenheit)  during  the  twenty- 
four  hours,  and  at  no  time  touches  the  normal,  it 
is  described  as  coiitiiiHed.  When  the  daily 
fluctuations  exceed  two  degrees,  it  is  known  as 
remittent  (Fig.  1):  and  when  fever  is  only  present 
for  several  hours  during  the  day  it  is  called  inter- 
mittent. In  remittent  fever  the  evening  tem 
perature  is  usually  higher  than  the  morning  one,  but 
in  some  cases,  not  infrequently  in  phthisis,  this  type 


40 


CoNniTlON  AND    ApPEARANCE. 


is  inverted^  and  the  "remission"  occurs  in  the  even- 
ing, whilst  there  is  a  morning  "  exacerbation."  When 
a  paroxysm  of  intermittent  fever  occurs  daily,  the  type 
is  said  to  be  "  quotidiaii  "  ;  when  on  alternate  days 


^     1    1     1 

Z      1      ^       1      z 

3     r     a     9^ 

/    2 

.... L»«, 

T-     -    T 

I-   -3 

It              4^ 

Jt 

lOli        \        -      -\ 

,01        -.       --       -^ 

1 

"'"{■■■■ 

1 

-\v      - 

..I5„^_._         A,       ^ 

_1 

,  ^  J  ^z^ 

d^^ 

\  y\  V 

i'^'sM             ' 

Quotidian         ^CT'tia.n  :  Qu,artun, 

Fig.  2.— Intermittent  fevers. 

"  tertian  ^' ;  when  two  days  intervene  between  consecu- 
tive attacks,  *'  quartan'^  (Fig.  2).    A  "  double  ter- 
tian "  is  the  name 
applied  to  a  daily 
fever     when     the 


.—JKBil „_^ 

■S^iSaa  ■■rjBSiii  ■riigBBl 

IICi8i»BBI'aiW 

■  ■■■■■IIBHH  ■■■■■■■■ 

!■■  ■■■!!■■■  ■«■■■■  ■■ 

■■■■■■(■■■■■■■■■lar 
■■■■■■■ 


Fig.  3. — Crisis.    Case  of  lobar  pneumonia. 
{After  Wiimlerlicli.) 


paroxysms  occur- 
ring on  the  first, 
third,  fifth,  and 
following  odd  days 
differ  from  those 
of  the  second, 
fourth,  sixth,  and 
following  even 
days  in  hour  of 
appearance,  in 
severity,  or  in 
character. 


The  Study  of  a  Ffa'er. 


41 


The  course  of  a  fever  is  divided  into  three 
stages — the  initial  or  pyrogenetic,  "  stadiicm  in- 
crementi  "y  the  stage  of  full  development,  or 
'■'■  fastigium" ;  and  the  stage  of  termination,  or 
'■''Stadium  decrementV^  When  the  fever  ends  rapidly 
it  is  said  to  resolve  by  "  crisis "  (Fig.  3) ;  when 
gradually,  by  "  lysis "  (Fig.  4).  Not  seldom  crisis 
is  preceded  by  a  short  but  marked  rise  of  tempera- 
ture, accompanied  in  many  cases  by  delirium  ;  it  is 
sometimes  followed  by 
collapse. 

In  the  study  of  any 
case  of  fever  the  points 
which  require  to  be  ob- 
served are  whether  the 
type  is  one  of  apathy  and 
indifiference,  or  of  rest- 
lessness and  twitching  ; 
whether,  and  if  so  how 
far,  the  sensorium  has  been 
involved;  what  the  height 
of  the  temperature  is,  and 
what  its  course  has  been ; 
what  are  the  rate  and 
character  of  the  pulse ; 
whether  the  skin  is  moist 

or  dry,  or  exhibits  any  eruption;  and  which  of  the 
viscera  or  secretions  are  characteristically  affected. 
The  explanation  of  these  points  may  be  found  in 
works  on  medicine,  but  their  true  significance  can 
only  be  learned  at  the  bedside. 


Fig.  4. — Lysis.     Case  of  bronclio- 
pneumonia.  (After  WunderUch). 


42 


CHAPTER  III. 

Alimentary  System  and  Abdomen. 
"SECTION   I. 

The  mouth. — For  the  examination  of  the  mouth 
the  patient  should  be  placed  facing  a  good  light. 
If  artiOcial  light  is  used  it  should  be  thrown  into  the 
mouth  by  means  of  a  reflector.  A  piece  of  candle 
wrapped  in  blotting-paper  and  held  in  front  of  a 
bright  spoon  forms  a  good  extemporised  light  and 
reflector. 

L.ips. — Note  the  colour  of  the  lips.  They  are 
blue  in  cyanosis,  pale  in  anaemia.  Note  the  presence 
of  any  crusts,  fissures,  or  ulcers.  The  lips  should 
be  everted  in  order  to  permit  of  an  examination  of 
their  inner  surfaces.  Herpes  of  the  lips  is  often  seen 
in  inflammatory  conditions  of  the  air-passages  and 
lungs,  especially  in  croupous  pneumonia. 

The  teeth. — The  temporary  teeth  are  cut  in  the 
following  order : — 

First. — The  two  lower  central  incisors,  sixth  to 
eighth  month. 

Second. — The  four  upper  incisors,  eighth  to  tenth 
month. 

Third. — The  lower  lateral  and  all  the  front  molars, 
twelfth  to  fourteenth  month. 

Fourth. — The  canines  (upper  first),  eighteenth  to 
twentieth  month. 

Fifth. — Posterior  molars,  at  two  to  two  and  a  half 
years. 

The  per^nanent  teeth  appear  as  follows  : — 

First  molar  at  six  years. 

Central  incisors  at  seven  years. 

Lateral  incisors  at  eight  years. 


The  Teeth.  43 

Bicuspid  (anterior)  at  nine  years. 
Bicuspid  (posterior)  at  ten  years. 
Canines  at  eleven  to  twelve  years. 
Second  molars  at  twelve  to  thirteen  years. 
Third  molars  at  seventeen  to  twenty-five  years. 
The  following  table  shows  the  relations  of  the  per- 
manent and  temporary  teeth  : — 


Temporary  i 


M.       C.        I. 
2         12 


1  Lower     2         12 
M.  Bi.    C.     I. 

Permanent  j  

\  Lower     3      2      12 


I.        C.        M. 

20 


2         1         2) 


I.      C.     Bi.    M. 
2      12      3 


1- 


The  presence  of  any  irregularity  or  defect  or 
carious  disease  in  the  teeth  should  be  noted.  It 
should  be  observed  whether  there  is  any  exposure 
of  their  i-oots,  or  whether  they  are  surrounded  with 
tartar.  Grinding  of  the  teeth  leads  to  bevelling  of 
their  edges;  this  is  specially  found  in  young  children. 
The  presence  of  "  Hutchinson's  teeth  "  is  important 
as  affording  evidence  of  congenital  syphilis.  In  this 
condition  the  two  central  upper  'permanent  incisors 
are  at  a  higher  level  than  the  adjoining  teeth,  they 
are  rounded  in  section  and  slope  inwards  below,  they 
are  broader  near  the  gum  than  at  the  crown  so  as 
to  be  peg-shaped,  and  they  present  a  semilunar  notch 
at  their  ends.  They  are  usually  discoloured  as  well. 
In  the  same  condition  the  molars  tend  to  be  dome- 
shaped. 

The  glims. — Their  colour  should  first  be  noted. 
In  lead  poisoning  a  blue  line  can  often  be  observed 
runnings  along  the  gum  near  the  insertion  of  the  teeth, 
and  especially,  perhaps,  on  the  gum  between  the  teeth. 
In  copper  poisoning  a  greenish  line  can  sometimes  be 
seen  in  a  similar  position.  The  gums  may  be  swollen 
and  spongy  in  scurvy.     They  are  sometimes  retracted, 


44  Alimentary  System. 

or  sliow  ulcerations  or  haemorrhages.  Ulcers  and 
haemorrhages  may  also  be  observed  in  the  buccal 
mucous  membrane  in  various  conditions. 

The  tong^ue. — Ask  the  patient  to  protrude  it. 
Note  if  it  is  put  out  in  a  straight  line.  Observe 
its  size  and  shape,  whether  broad  or  pointed.  Look 
for  tremulousness  of  the  whole  tongue  and  for  fibril- 


■pjg.  5._o,  Scraping  from  a  patch  of  thrush  ;   x  800.    h.  Culture  of  sac- 
charomyces  albicans  (monilia  Candida) — the  fungus  of  thrush  ;   x  800. 

lary  twitching  of  it.  Note  in  the  dorsum  (1)  its 
colour  :  Is  it  pale,  red,  or  discoloured  1  (2)  Is  it  dry 
or  moist *?  (3)  The  presence  or  absence  of  fur;  the 
colour  and  distribution  of  the  latter  should  be  noted. 
(4)  The  character  of  the  papillre.  (5)  The  under  sur- 
face of  the  tongue — a  small  ulcer  on  the  fraenum  is 
sometimes  seen  in  persistent  coughing,  and  particu- 
larly in  whooping  cough.  Lastly  (6),  observe  the 
edges  of  the  tongue.  Look  for  ulcers,  indentations 
of  the  teeth,  etc.,  on  them. 

The  presence  of  tlirusli  may  sometimes  be  observed 


The  Tongue.  45 

on  the  surface  of  the  buccal  mucous  membrane,  espe- 
cially in  children.  It  presents  the  appearance  of 
small  white  points  or  patches  raised  somewhat  above 
the  surrounding  surface,  which  is  sometimes  redder 
than  normal.  Patches  of  thrush  are  very  apt  to  be 
mistaken  for  small  milk  curds.  They  may  be  distin- 
guished by  the  fact  that  milk  curds  can  be  easily 
detached,  while  thrush  i:)atches  can  only  be  removed 
with  difficulty,  and  when  removed  are  apt  to  leave 
behind  a  raw  surface.  To  search  for  the  fungus 
(saccharomyces  albicans)  a  small  piece  of  the  patch 
should  be  scraped  off  and  examined  in  a  drop  of 
glycerine.  A  quantity  of  epithelial  debris^  along 
with  bacteria  and  leucocytes,  will  be  seen,  and 
mixed  up  with  these  the  filaments  of  the  fungus. 
These  consist  of  long  but  unequal  segments,  each 
usually  possessing  a  refractile  nucleus  at  each  end 
(Fig.  5). 

The  palate,  fauces,  and  pharynx. — Intro- 
duce a  tongue  depressor,  and  note  first  the  general 
colour  of  the  soft  palate,  fauces,  and  pharynx ;  ob- 
serve any  abnormal  degree  of  pallor  or  redness.  The 
yellow  tinge  of  jaundice  often  lingers  long  on  the 
soft  palate,  and  in  commencing  measles  a  patchy  red- 
ness can  be  made  out  very  early  in  the  same  situation. 
Note  the  presence  of  any  ulcers  or  mucous  patches  on 
the  palate,  fauces,  or  tonsils.  Look  carefully  at  the 
tonsils,  noting  any  enlargement  of  them.  Yellowish 
or  greyish  points  or  patches  may  sometimes  be  seen 
on  their  surface.  Try  whether  these  can  be  wiped 
oflf  leaving  a  sound  surface,  as  is  the  case  with  ac- 
cumulated follicular  secretion,  or  whether  removal 
leaves  behind  a  raw  surface,  as  happens  with  the  false 
membrane  of  diphtheria.  Note  always  whether  or 
not  the  soft  palate  and  uvula  show  any  similar  spots 
or  patches.  Next  look  at  the  pharynx.  The 
presence  upon  its  surface  of  a  number  of  flat  adenoid 


46  Alimentary  System. 

swellings,  somewhat  resembling  sago  grains,  is  so 
common  as  to  be  almost  a  normal  appearance.  In 
granular  pharyngitis  these  are  much  increased.  A 
few  dilated  venules  can  also  be  frequently  observed. 
Note  the  presence  of  any  pus  or  excess  of  mucus 
on  the  surface,  and  the  existence  of  any  ulceration. 
In  retro-pharyngeal  abscess  the  posterior  wall  of  the 
pharynx  is  bulged  inwards.  Sometimes  this  can  be 
more  easily  made  out  by  palpation. 

The  breath. — The  character  of  the  breath  may 
be  noted  at  this  stage.  If  it  is  offensive,  ask  the 
patient  to  breathe  out  first  through  the  nose  only,  and 
then  through  the  mouth,  and  observe  whether  the 
odour  is  present  on  both  occasions  or  not.  This 
affords  an  indication  as  to  whether  the  source  of  the 
odour  is  in  the  nose  or  mouth  only,  or  whether  it 
is  lower  down  than  either.  If  the  odour  proceeds 
from  the  nose,  make  a  rhinoscopic  examination  (p.  477), 
looking  especially  for  the  presence  of  a  foreign  body 
or  for  evidence  of  atrophic  rhinitis  or  other  local 
disease.  Bad  teeth,  ulcerations  of  the  gums  or  mucous 
membrane,  and  enlarged  tonsils  accompanied  by 
retention  and  decomposition  of  secretion  in  their 
follicles,  are  the  commonest  sources  of  offensiveness 
in  the  mouth. 

In  gangrene  of  the  lung  the  breath  has  a  putrid 
smell.  In  bronchiectasis,  also,  it  has  a  peculiarly 
offensive  odour  only  to  be  recognised  by  experience. 
Foetor  due  to  pulmonary  conditions  is  best  brought 
out  by  asking  the  patient  to  cough. 

Slighter  degrees  of  offensiveness  may  be  due  to 
gastric  disorder  or  to  prolonged  constipation. 

In  uraemia  the  breath  has  a  urinous  or  ammoniacal 
odour.  In  diabetes  it  is  sweetish,  like  new-mown 
hay.  In  cases  where  diabetic  coma  is  impending, 
the  odour  becomes  ethereal.  Various  drugs — e.g. 
turpentine,   creasote,  paraldehyde,   etc.,  impart  their 


Exploration  of  (Esophagus.  47 

characteristic  odours  to  the  breath,  while  in  the  case 
of  patients  who  are  taking  bismuth  a  garlicky  odour 
can  often  be  observed. 

The  oesophagus. 

Special  anatomy. — The  cesophagus  is  from 
10  in.  to  12  in.  long.  It  begins  opposite  the  cricoid 
cartilage,  and  ends  opposite  the  ninth  dorsal  spine. 
It  is  crossed  by  the  left  bronchus  between  the  fourth 
and  fifth  dorsal  vertebrae. 

Exploration  of  the  oesophagns. — This  is 
done  in  cases  in  which  there  are  signs  of  stricture.  It 
is  best  carried  out  by  means  of  a  stomach  tube.  The 
latter  should  never  be  passed,  however,  unless  one  has 
first  excluded  the  possibility  of  the  existence  of  an 
aneurysm.  It  should  also  be  avoided  in  cases  where 
there  has  been  any  recent  haematemesis. 

It  is  best  to  use  a  long,  red  rubber  stomach  tube. 
It  should  be  at  least  a  yard  long — ^not  too  thin  in  the 
wall,  rounded  at  the  end^  and  with  at  least  one  large 
eye.  Previous  to  being  used,  it  should  be  thoroughly 
cleaned,  and  then  dipped  in  hot  water;  oil  is  un- 
necessary. 

The  patient  should  be  sitting  up,  with  the  head 
slightly  bent  forwards.  His  mouth  is  open,  but  the 
tongue  not  protruded.  The  physician  grasps  the  tube 
in  his  right  hand,  and  passes  it  back  in  the  middle 
line  to  the  posterior  Avail  of  the  pharynx.  It  is  not 
usually  necessary  to  introduce  a  finger  into  the  mouth 
in  order  to  guide  the  tube,  as  there  is  no  real  danger 
of  entering  the  larynx.  The  patient  is  then  told  to 
swallow,  and  the  tube  is  "payed  out"  until  it 
reaches  the  stomach,  or  until  it  is  permanently 
arrested. 

During  this  manipulation  one  has  to  look  out  for 
the  following  :  (1)  Pain  on  passing  the  tube  ;  its  site 
should  be  noted.     (2)  The  presence  of  an  obstruction. 


48  Alimentary  System. 

If  the  tube  is  arrested,  one  must  not  conclude  all  at 
once  that  a  stricture  exists.  Frequently  the  tube  is 
seized  by  a  muscular  spasm  of  the  oesophagus.  On 
waiting  for  a  moment,  however,  this  always  passes  off. 
If  a  permanent  obstruction  be  discovered,  one  has 
to  attempt  to  localise  it.  The  commonest  sites  for 
a  stricture  are — {a)  At  the  entrance ;  this  is  6  in. 
from  the  incisor  teeth.  (6)  Where  the  oesophagus  is 
crossed  by  the  left  bronchus ;  this  is  8  in.  to  9  in. 
from  the  teeth,  (c)  At  the  cardiac  orifice ;  this  is 
about  17  in.  from  the  teeth. 

It  is  interesting  to  note  that  these  are  also  the 
positions  in  which  some  normal  narrowing  of  the 
oesophagus  exists. 

(3)  One  has  to  look  for  diverticula.  The  existence 
of  such  should  be  suspected  when  the  tube  passes 
very  readily  at  one  time,  but  is  obstructed  at 
another. 

The  presence  of  any  blood  on  the  tube  after  its 
withdrawal  is  an  indication  of  the  presence  of  ulcer- 
ation. Sometimes,  also,  fragments  of  new  growth  can 
be  detected  in  the  eye  of  the  tube. 

Atisciiitatioii  of  the  OBisopliagits. — This  is 
done  in  order  to  note  the  presence  or  absence  of 
the  sound  produced  by  swallowing.  In  order  to  aus- 
cultate the  oesophagus  in  the  neck,  the  stethoscope 
should  be  placed  at  the  left  side  of  the  trachea.  In 
the  upper  part  of  the  thoracic  course  of  the  oesophagus 
(as  far  as  the  6th  dorsal  vertebra)  it  should  be  placed 
just  to  the  left  of  the  dorsal  spines,  and  below  this  just 
to  their  right.  The  patient  is  told  to  take  a  mouthful 
of  water,  and  to  retain  it  until  told  to  swallow.  When 
he  swallows,  one  hears  a  noise  similar  to  that  heard 
in  one's  own  ear  on  swallowing  saliva.  The  higher 
up  one  listens,  the  louder  is  this  sound.  If  an  obstruc- 
tion is  present,  the  sound  is  either  not  heard  at  all 
below  that  point,  or  it  is  greatly  delayed. 


AnDOMINAL    J^F.GIOXS.  49 

SECTION  II.— THE   ABDOMEN. 

Anatomy ^The  natural  lines  on  the  surface  of 

the  abdomen  are,  (1)  the  linea  alba;  (2)  the  linese 
semilunares  ;  (3)  the  linea3  transversa?. 

The  linea  alba  is  often  selected  as  the  site  of 
puncture  in  tapping  the  abdomen.  The  structures 
lying  behind  it,  from  above  downwards,  are  {a)  the 
left  lobe  of  the  liver,  extending  to  about  three 
lingers'  breadths  below  the  ensiform  ;  (h)  part  of  the 
stomach,  unless  when  empty ;  (c)  the  transverse 
colon,  reaching  as  low  as  the  umbilicus ;  {d)  coils  of 
intestine  covered  by  omentum  ;  (e)  the  bladder  when 
distended,  and  the  uterus  when  pregnant. 

The  linea  semilunaris  runs  from  the  lowest  part 
of  the  seventh  rib  to  the  spine  of  the  pubes.  It  is 
about  three  inches  from  the  umbilicus,  but  lies 
farther  out  when  the  abdomen  is  distended.  The 
gall  bladder  lies  just  to  the  outer  side  of  the  linea 
semilunaris  of  the  right  side. 

Of  the  linece  transversce  one  is  opposite  the  um- 
bilicus, another  at  the  ensiform,  and  a  third  midway 
between  these  points.  In  addition  to  these  markings, 
the  abdomen  has  been  artificially  divided  into  regions 
by  means  of  vertical  and  horizontal  lines.  The  vertical 
lines  are  drawn  upwards  from  the  mid  point  of  Pou- 
part's  ligament  on  each  side.  The  transverse  lines  are 
(1)  the  infracostal,  drawn  across  horizontally  at  the 
level  of  the  lowest  points  of  the  10th  costal  cartilages, 
and  (2)  the  bi-iliac,  between  the  most  prominent  points 
of  each  iliac  crest.  Nine  regions  are  thus  marked  off 
in  three  vertical  rows.  Those  in  the  middle  row 
are,  from  above  downwards,  the  epigastric,  umbilical, 
and  hypogastric,  and  in  each  lateral  row  we  have 
the  (right  or  left)  hypochondriac,  lumbar,  and  iliac 
regions.  The  contents  of  these  regions  are  exhibited 
in  the  following  table  : — 


5° 


The  Abdomen. 


o 

s 

< 

o 

« 

DQ 

G 
% 

III 

o 

> 

f— 1 

o 

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w 

-§ 

H 

^ 

^ 

ew 

O 

-U 

C^ 

(In 

^    a 


O    m 


Pico 


&t 


ft  M 


03      03 


S   o 
p  — 

Ed    'iH 


H^      :3 


Ph 


60 
g 


o3 


I 


p 

Cl) 

d 

!i 

el 

d 

s 

M 

o    "o 

■o     ^^ 


cp 


be 

d 

M 

liver. 
f  livei 

cludin 

rfi 

be  of 
lobe  c 

ach  in 

O 
1— ( 

Oi 

'■^ 

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P^^l^ 

^  o^  ^ 

f-l    r^    --J      JH 

o3  b>.    '5    <'S 

p    Ph 

(U  =f-l 

■t:^   o 

!■? 

^    O)       . 

2;   © 

CM     03   ^     fl 
'O    (D    O    ^ 

S    O    «>    S 

^  a  s  & 


(4 

o 

p 

•is 

» 

1— t 

o 

=w 

» 

o 

o 

03 

>^ 

1— 1 

M 

(^ 

H 

«f-l 

IS 

o 

2       -^^ 


P^ 


o 


rt 


© 

a 

pi 


c3 


g     © 

2  M 


o 

oo 

o 
o 

a 

bn 

© 

a 

Ti 

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rt 

O 

© 

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02 

(t! 

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P4 

w   S 

M        © 

p:5  r^i 


General  Examination.  51 

T]ie  umbilicus  is  \\  in.  to  \\  in.  above  the  level 
of  the  bi-iliac  line,  and  lies  opposite  the  upper  part  of 
the  4th  lumbar  vertebra. 

The  aorta  bifurcates  about  |-  in.  below  and 
slightly  to  the  left  of  the  umbilicus,  the  iliac  arteries 
running  in  a  line  drawn  from  that  point  to  the 
middle  of  Poupart's  ligament. 

The  cceliac  axis  arises  at  a  point  4^-  in.  to  5  in. 
above  the  umbilicus,  and  the  renal  arteries  about 
an  inch  lower  than  the  coeliac  axis. 

General  Examination  of  Abdomen. 

The  patient  should  be  lying  on  his  back  in  a  good 
light.  The  abdomen  is  exposed  by  turning  down  all 
the  bedclothes  except  the  inner  sheet.  The  night- 
shirt should  then  be  drawn  up,  and,  lastly,  the  sheet 
folded  down  a  little  above  the  level  of  the  pubes. 
These  details  are  of  especial  importance  in  the  case  of 
female  patients.  Before  beginning  the  examination 
of  the  abdomen,  make  sure  that  the  bladder  is  empty. 
If  necessary,  a  catheter  must  be  passed. 

Inspection  of  abdomen. — Look  first  at  the 
general  contour  of  the  abdomen.  Is  it  of  normal 
fulness,  is  it  swollen  or  protuberant,  or  is  it  sunken 
or  retracted  %  If  there  is  any  bulging,  note  if  it  be 
general  or  local.  General  fulness,  it  has  been  epi- 
grammatically  remarked  by  Dr.  Wyllie,  may  be  due 
to  "fat,  fluid,  or  flatus."  If  one  were  to  venture 
to  improve  upon  this,  it  would  be  to  say,  ' '  fat,  fluid, 
gas,  or  growth^''  as  new  growths  are  a  not  unfrequent 
cause  of  general  abdominal  tumidity.  The  mode  of 
distinguishing  these  conditions  will  be  considered 
when  we  come  to  ascites.  In  general  bulging  it 
should  be  noted  whether  the  distension  is  most 
marked  in  the  antero-posterior  or  in  the  transverse 
diameter. 

If  the  bulging  be  merely  local,  observe  in  which 


52  The  Abdomen. 

zone  it  is  situated.  Is  it  above  or  below  the  level 
of  the  umbilicus,  and  in  which  of  the  abdominal 
regions  is  it  most  marked  %  Lastly,  note  if  there 
is  any  movement  to  be  seen  in  the  swelling,  either 
along  with  or  independently  of  respiration. 

Puli!»at)ioii  in  the  epig^astric  re$^ioii  is  a 
phenomenon  which  may  be  noticed  on  abdominal 
inspection^  apart  from  any  bulging  in  that  region. 
The  causes  of  it  are  (1)  distension  of  the  right 
ventricle  (see  p.  106) ;  (2)  venous  pulsation  of  the 
liver  ;  (3)  aortic  pulsation.  The  last  is  a  condition 
which  is  very  frequently  observed  in  nervous  subjects, 
especially  women.  The  cause  of  it  is  obscure.  It 
may  be  distinguished  from  right  ventricle  pulsation 
by  being  situated  somewhat  to  the  left  of  the  middle 
line,  by  the  fact  that  it  can  usually  be  traced  down- 
wards towards  the  bifurcation  of  the  aorta,  and  by  its 
being  not  quite  synchronous  with  the  apex  beat,  but 
somewhat  delayed.  (4)  Transmitted  pulsation  from  a 
tumour  overlying  the  aorta.  (5)  Aneurysmal.  This 
iS;  perhaps,  the  least  common  cause  of  epigastric 
pulsation.  The  pulsation  in  this  case  is  expansile, 
a  fact  which  can  best  be  elicited  by  placing  the 
narrow  ends  of  two  stethoscopes  one  on  each  side 
of  the  swelling,  and  observing  if  the  other  ends  move 
apart  at  each  impulse. 

The  movements  of  the  abdominal  wallis 
should  be  studied.  Normally,  they  bulge  during 
inspiration,  and  fall  in  again  during  expiration.  In 
paralysis  of  the  diaphragm  the  reverse  holds  true ; 
sometimes  the  paralysis  is  unilateral,  in  which  case 
one  side  of  the  abdomen  will  move  naturally.  Ces- 
sation of  movement  of  the  abdominal  walls  is  a 
valuable  sign  of  peritonitis. 

Sometimes  peristaltic  waves  are  visible  through 
the  abdominal  wall.  This  is  especially  apt  to  be  the 
case  in   chronic  intestinal  obstruction.     The  coils  of 


Inspection.  53 

intestine  above  the  constricted  part  then  stand  out 
prominently.  From  this  a  definite  "  pattern "  of 
abdominal  tumidity  results,  depending  on  the  site  of 
the  obstruction.  If,  for  example,  there  be  a  constric- 
tion at  the  ileo-c?ecal  valve,  the  distended  coils  of 
small  intestine  may  often  be  observed  standing  out  in 
the  centre  of  the  abdomen  one  above  the  other,  so  as 
to  form  a  "ladder  pattern."  On  the  other  hand,  if 
the  obstruction  be  low  down,  say  in  the  sigmoid 
flexure,  the  pattern  of  tumidity  is  one  in  which  the 
periphery  of  the  abdomen  is  chiefl.y  affected.  A  dilated 
stomach  may  also  stand  out  as  a  prominent  tumour  in 
which  peristaltic  waves  are  visible.  The  direction  of 
such  waves  should  always  be  noted.  If  absent,  they 
can  often  be  elicited  by  flicking  the  surface  with 
a  wet  towel,  or  by  merely  sharply  tapping  it  with 
the  finger.  Peristaltic  waves  in  the  stomach  run 
from  left  to  right ;  those  in  a  distended  transverse 
colon  from  right  to  left.  This  may  sometimes  be  of 
diagnostic  value. 

Attention  should  next  be  paid  to  the  surface  ot 
the  abdomen.  In  great  distension  the  surface  is 
smooth  and  glossy.  Striae  (white  lines  in  the 
epidermis)  should  be  looked  for ;  they  indicate  former 
distension.  Note  any  distension  of  the  surface 
veins,  and  endeavour  to  ascertain  in  what  direction 
the  blood  in  them  is  flowing.  In  obstruction 
of  the  inferior  vena  cava,  the  inferior  epigastric 
veins  are  full  from  the  establishment  of  a  collateral 
circulation.  In  such  cases  also  a  large  lateral  vein 
can  be  seen  running  up  about  the  mid-axillary  line, 
and  thus  establishing  a  communication  with  the  tribu- 
taries of  the  superior  vena  cava.  In  portal  obstruc- 
tion a  number  of  distended  veins  may  often  be  seen 
radiating  out  from  the  umbilicus.  To  this  appear- 
ance the  term  "  caput  medusae "  has  been  applied. 
It  is  due  to  establishment  of  a  connection  between 


54  The  Abdomen. 

tlie  portal  and  parietal  veins  by  means  of  the  round 
ligament.  Pigmentation  of  the  abdominal  wall  is 
sometimes  important.  Along  the  middle  line  it  forms 
the  linea  nigra — one  of  the  signs  of  pregnancy. 
Note  the  appearance  of  the  umhilicus.  Is  it  de- 
pressed, level  with  the  surface,  or  bulging  ?  Is  there 
any  excoriation  around  it  ?  Lastly,  one  should 
never  omit  to  look  at  the  usual  sites  for  any  evidence 
of  hernia. 

Palpation  of  the  abdomen. — The  patient 
should  be  on  his  back,  with  the  knees  drawn  up, 
and  the  shoulders  a  little  raised.  He  should 
be  told  to  keep  the  mouth  open  and  to  breathe 
quietly,  or  his  attention  may  be  diverted  l)y  conver- 
sation. The  hand  of  the  physician  must  be  warm. 
Ordinary  palpation  should  be  performed  with  one 
hand  only.  In  order  to  gain  the  confidence  of  the 
patient's  abdominal  muscles,  the  hand  should  be 
allowed  to  rest  for  a  moment  on  the  surface  of  the 
abdomen  before  palpation  is  actually  commenced. 
Each  I'egion  should  be  palpated  systematically. 
Poking  with  the  finger  tips  should  be  avoided,  the 
best  movement  being  a  gentle  one  from  the  metacarpo- 
phalangeal joints.  During  expiration  the  receding 
abdominal  wall  should  be  followed  by  the  fingers, 
and  a  gentle  rotatory  motion  of  tlie  finger  tips  may 
then  be  carried  out.  It  often  enables  one  to  feel  the 
deeper  structures  better  than  one  can  do  by  simple 
pressure.  In  examining  the  lateral  regions  of  the 
abdomen,  bimanual  palpation  is  often  of  service.  The 
physician  should  sit  or  kneel  by  the  bedside.  One 
hand  is  placed  posteriorly  in  the  interspace  between 
the  last  rib  and  the  crest  of  the  ilium.  The  other  is 
placed  over  the  abdominal  wall  in  front.  The  posterior 
wall  is  then  pushed  up  against  the  hand  in  front,  so 
that  any  structure  lying  between  the  two  hands  can 
be  distinctly  felt.     The  secret  of  the  method  consists 


Palpation.  55 

in  keeping  the  front  hand  as  still  as  possible.  This 
procedure  is  of  special  value  in  the  examination  of 
the  kidneys. 

The  first  thing  to  notice  in  palpation  of  the  abdo- 
men is  the  degree  of  resistance  experienced.  Normally 
the  abdomen  has  an  elastic  or  doughy  feeling  only  to 
be  learnt  by  practice.  In  disease  the  resistance  may 
be  increased.  It  should  be  observed  whether  this 
increase  is  general  or  local.  General  peritonitis  pro- 
duces a  great  increase  in  the  resistance  from  a  reflex 
contraction  of  the  muscles  of  the  abdominal  wall. 
Local  increase  in  resistance  is  very  frequently  due  to 
localised  peritonitis,  and  is  often  of  great  diagnostic 
value.  Palpation  of  the  normal  abdomen  is  painless. 
If  tenderness  is  elicited,  its  exact  extent  and  point 
of  maximum  intensity  should  be  noted.  Anything  of 
the  nature  of  a  tumour  should  be  carefully  felt  for. 
In  doing  this,  confusion  is  apt  to  be  brought  about  by 
the  recti.  The  thickening  produced  by  parts  of  these 
may  easily  simulate  a  tumour.  If  this  source  of 
fallacy  be  suspected,  try  if  the  fingers  can  be  got 
under  the  edge  of  the  muscle,  and  feel  if  it  thickens 
as  the  patient  raises  himself  in  bed. 

If  it  be  decided  that  a  tumour  is  really  present, 
one  has  first  to  determine  whether  it  is  situated  inside 
the  abdomen  or  in  the  abdominal  wall.  Try,  there- 
fore, to  move  the  abdominal  wall  from  side  to  side 
over  the  tumour.  If  the  growth  be  intra-abdominal, 
this  can  usually  be  done  without  difficulty,  unless  it 
has  contracted  adhesions  to  the  parietal  peritoneum. 
Try  also  to  grasp  the  tumour  and  to  make  the  fingers 
meet,  as  it  were,  under  it.  This  can'  usually  be 
accomplished  in  the  case  of  tumours  situated  wholly 
in  the  abdominal  wall. 

Supposing  the  tumour  to  be  intra-abdominal,  the 
first  question  to  be  settled  is — Where  is  it  growing 
from?  and,   especially,    is    it   coming   up   out   of   the 


56  The  Abdomen. 

pelvis,  or  is  it  truly  abdominal  %  To  decide  this  the 
edge  of  the  hand  should  be  pushed  back  about  an 
inch  below  the  umbilicus,  and  in  the  direction  of  the 
prominence  of  the  sacrum.  One  can  then  feel 
whether  the  tumour  is  passing  down  into  the  pelvis 
or  not.  The  size  and  shape  of  the  tumour  should  next 
be  noted,  and  the  nature  of  its  surface — whether 
smooth  or  nodular.  The  presence  or  absence  of  fluc- 
tuation should  then  be  investigated. 

The  mobility  of  a  tumour  is  a  very  important 
point  to  determine.  The  directions  in  which  it  can 
be  moved  should  be  noted,  and  whether  it  is 
influenced  by  respiration.  The  latter  is  a  point  of 
special  value.  Tumours  connected  with  the  liver 
and  spleen  move  freely  with  respiration.  Tumours 
of  "the  kidney  may  be  slightly  movable ;  those  con- 
nected with  the  other  abdominal  organs  do  not  move 
with  respiration  at  all  unless  they  have  contracted 
adhesions. 

In  palpating  the  abdomen,  the  existence  of  splash- 
ing or  gurgling  at  any  points  should  be  looked  for. 
Splashing  is  often  found  over  a  dilated  stomach,  but 
is  only  of  diagnostic  value  if  it  can  be  elicited  some 
hours  after  the  swallowing  of  food.  Gurgling  is  pro- 
duced by  the  passage  of  gas  and  fluid  through  con- 
stricted parts  of  the  alimentary  tract.  It  may  thus 
be  felt  at  the  pylorus,  especially  if  stenosed,  or  over 
strictures  of  the  intestines. 

Finally,  the  umbilicus  should  be  examined.  In 
malignant  disease  of  the  liver  the  umbilicus  often 
becomes  early  infiltrated,  and  this  sign  has  proved 
of  great  diagnostic  value.  The  infiltration  can  often 
be  recognised  by  its  producing  a  "  mooring  "  of  the 
umbilicus — just  as  a  scirrhus  of  the  mamma  does  of 
the  nipple. 

In  conclusion,  we  have  to  remark  that  in  obscure 
cases  of    abdominal  disease    palpation    in    the    knee- 


Percussion.  57 

elbow  position,  and  under  an  anaesthetic,  should  never 
be  omitted. 

Percussion  of  abdomen. 

Percussion  should  be  carried  out  in  the  same 
manner  as  will  be  described  for  the  chest.  We 
would  point  out,  however,  that  in  abdominal  percus- 
sion the  "  flicking  "  method  is  extremely  serviceable 
in  detecting  slight  degrees  of  dulness — e.y.  in  making 
out  the  lower  edge  of  the  liver.  In  carrying  out  this 
method  the  fore  finger  of  the  left  hand  is  placed  firmly 
on  the  abdomen,  with  the  palmar  aspect  uppermost, 
and  is  then  sharply  "  flicked  "  with  the  middle  finger 
of  the  right  hand.  Percussion  of  the  normal  abdomen 
yields  a  resonant  note  throughout,  except  in  the 
regions  of  liver  and  splenic  dulness.  The  ])ercussion 
pitch  of  the  hollow  viscera  depends  on  two  chief 
factors — ■ 

(«)  The  depth  of  the  air  space. 

(6)  The  tension  of  the  containing  wall. 

As  these  two  factors  are  of  almost  equal  import- 
ance, and  as  each  of  them  varies  greatly  in  the  same 
viscus  at  different  times,  the  reader  will  readily 
understand  that  it  is  a  mistake  to  dogmatise  about 
the  relative  pitch  of  the  note  yielded  by  the  various 
hollow  viscera.  Other  things  being  equal,  however, 
the  smaller  air-space  of  the  small  intestine  will  yield  a 
higher  pitched  note  than  the  larger  air-space  of  the 
colon.  The  presence  of  free  gas  in  the  peritoneal 
cavity  causes  the  normal  liver  and  spleen  dulness  to 
disappear. 

If  any  abnormal  dulness  be  detected,  the  chief 
point  to  be  determined  regarding  it  is  whether  it  is 
constant  in  position  or  shifts  with  alterations  in  the 
position  of  the  patient.  This  will  be  more  fully  dis- 
cussed when  we  come  to  speak  of  ascites. 

Hydatid  cysts  yield  on  percussion  a  special  kind 
of  vibration  called  the  "  hydatid  thrill  "  (fremissement 


58  The  Abdomen, 

hydatique).  To  elicit  it  three  fingers  should  be  placed 
over  the  cyst  and  the  middle  one  firmly  percussed, 
the  percussing  finger  being  allowed  to  rest  for  a 
moment  after  each  stroke.  An  "  after-thrill "  will 
then  be  experienced  in  the  two  adjacent  fingers.  It 
should  be  added  that  the  sign  is  absent  in  about  half 
the  cases  of  hydatid  cyst. 

Auscultation  of  abdomen. 

Auscultation  is  not  of  much  service  in  the  exami- 
nation of  the  abdomen.  It  is  best  to  carry  it  out  by 
means  of  a  binaural  stethoscope.  In  the  region  of  the 
stomach  one  may  listen  for  swallowing  sounds,  bub- 
bling and  splashing  (to  be  described  later),  or  for 
abnormal  conduction  of  heart  sounds.  Elsewhere 
one  may  hear  friction  sounds — from  the  presence  of 
lymph  on  the  surface  of  the  peritoneum.  One  may 
listen  over  aneurysms  to  detect  a  bruit,  and  over 
suspected  enlargement  of  the  uterus  for  the  presence 
of  foetal  heart  sounds.  The  latter  are  best  heard  (in 
normal  presentations)  at  a  point  midway  between  the 
umbilicus  and  the  left  anterior  superior  spine. 

The  examination  of  the  abdomen  by  the  combined 
auscultation-percussion  method  will  be  referred  to 
later. 

In  cases  of  general  abdominal  swelling  measure- 
ment should  never  be  omitted,  as  it  affords  a  valuable 
index  of  the  progress  of  the  case.  The  circumference 
may  be  taken  at  the  level  of  the  umbilicus  or  at  the 
point  of  maximum  distension. 

The  examination  of  cases  which  are  believed  to 
have  fluid  in  the  peritoneal  cavity  or  ascites  calls 
for  special  consideration.  In  cases  in  which  the  fluid 
is  sufficient  to  cause  general  distension,  the  conditions 
for  which  one  is  apt  to  mistake  it,  are,  as  we 
have  seen,  fat  in  the  abdomen  and  abdominal  wall, 
gas  in  the  intestines  or  free  in  the  peritoneum,  and 
new  growths.      Fluid   gives,  of  course,  a  dull  note 


A  use  UL  TA  TION.  5  Q 

on  percussion.  The  dulness  is  not  always  absolute, 
however,  owing  to  the  transmitted  resonance  of  sub- 
jacent bowel.  When  the  fluid  is  free  and  not  suffi- 
cient to  fill  the  whole  abdomen,  its  upper  limit  is 
more  or  less  horizontal,  but  may  show  irregularities 
owing  to  the  fluid  running  up  into  "  bays  "  between 
coils  of  bowel. 

Free  fluid  is  also  distinguished  by  the  fact  that 
it  shifts  its  position  with  that  of  the  patient.  If 
he  be  turned  over  on  his  side  and  time  given  for 
the  intestines  to  float  up,  it  will  be  found  that  the 
uppermost  flank  is  now  resonant,  while  the  height 
of  the  dulness  on  the  lower  side  has  risen.  If  the 
fluid  be  very  small  in  amount,  it  is  a  good  plan  to 
turn  the  patient  on  his  hands  and  knees.  A  dull 
area  then  appears  around  the  umbilicus  from  accumu- 
lation of  fluid  there. 

The  "  transmitted  thrill "  is  another  important 
physical  sign  of  fluid  in  the  peritoneum.  It  is  elicited 
by  placing  one  hand  over  the  lumbar  region  of  one 
side,  the  patient  being  on  his  back,  while  the  opposite 
lumbar  region  is  sharply  tapped  with  the  fingers  of 
the  other  hand.  A  distinct  impact  will  be  felt  to 
pass  from  one  hand  to  the  other.  As  a  not  dissimilar 
impulse  is  apt  to  be  transmitted  through  the  abdo- 
minal wall,  especially  if  fat,  it  is  always  well  to  get 
an  assistant  to  place  the  edge  of  his  hand  firmly  in 
the  middle  line  of  the  abdomen  while  percussion  is 
being  made.  This  damps  down  any  vibrations  trans- 
mitted by  the  wall.  Where  the  amount  of  fiuid  is 
large,  the  vibrations  are  visible  as  well  as  palpable. 
On  the  whole  we  consider  that  the  results  of  simple 
percussion  afford  the  most  trustworthy  evidence  of 
the  presence  of  ascites. 

Fati^  to  be  distinguished  by  taking  the  abdominal 
wall  between  the  hands  and  pinching  it  up.  Gas 
is  distinguished  by  the  results  of  percussion.     Of  new 


6o  The  Abdomen. 

growths,  ovarian  tumour  is,  perhaps,  most  liable  to 
be  mistaken  for  ascites.  An  ovarian  tumour,  how- 
ever, causes  an  antero-posterior  bulging  of  the  ab- 
domen, while  in  ascites  the  bulging  is  mainly  lateral. 
In  ovarian  tumours,  also,  the  dulness  is  central  and 
does  not  change  with  the  position  of  the  patient;  in 
ascites  the  chief  dulness  is  in  the  flanks,  and  it  shifts, 
as  we  have  seen,  when  the  patient  is  moved.  Lastly, 
in  ascites  the  umbilicus  is  flat  or  bulges  out,  while  in 
ovarian  tumours  it  is  drawn  upwards. 

SECTION  III. 

One  may  now  pass  to  the  examination  of  the 
viscera  contained  in  the  abdomen,  beginning  with  the 
stomach. 

The  Stomach. 

Special   anatomy  (Plates  L,  11. ). 

The  stomach  is  situated  in  the  left  hypochondriac 
and  the  epigastric  regions.  Its  cardiac  orifice  lies 
behind  the  seventh  left  costal  cartilage,  one  inch  from 
the  sternum  and  four  inches  from  the  surface.  The 
pyloric  orifice  is  surprisingly  close  to  it,  being  about 
three  fingers'  breadths  below  the  base  of  the  xiphis- 
terum  and  one  finger's  breadth  to  the  right  of  the 
middle  line.  It  passes  considerably  farther  to  the 
right,  however,  when  the  organ  is  distended.  It  is 
usually  under  cover  of  the  liver.  About  two-thirds 
of  the  stomach  is  under  cover  of  the  ribs,  the  fundus 
reaching,  in  ordinary  circumstances,  as  far  up  as  the 
fifth  rib  in  the  mammary  line.  It  is,  therefore, 
somewhat  behind  and  above  the  apex  of  the  heart. 
Only  a  small  part  of  the  body  of  the  stomach  and 
of  the  pyloric  region  is  in  contact  with  the  anterior 
abdominal  wall.  The  exact  position  of  the  great  cur- 
vature varies.  Under  normal  conditions  it  should 
never  be  lower  than  the  level  of  the  iwibilicus. 


/    j3RQCii 


PLATE   I.— VISCERA   OF  THORAX   AND    ABDOMEN,    AS   SEEN    FROM 
THE  FRONT.     Scale  :  1  =  5-6.     (After  LuscJiTca.) 

{To  face  p.  61. 


The  Stomach.  6t 

The  physical  oxannnation  of  the  stomach  is  chiefly 
concerned  ^vith  the  determination  of  its  size.  It  is 
by  no  means  easy  to  be  sure  of  the  exact  dimen- 
sions of  the  stomach,  owing  in  part  to  its  position, 
in  part  to  the  fact  that  the  amount  of  gas  contained 
in  it  varies  greatly  from  time  to  time.  The  fact  that 
it  is  in  direct  contact  with  the  transverse  colon,  which 
yields  a  very  similar  note,  also  adds  to  the  confusion. 

Recourse  is  frequently  had  to  inflation  of  the 
stomach  with  gas  in  order  to  overcome  some  of  these 
difficulties.  Inflation  may  be  carried  out  in  two 
ways  : — 

(1)  Make  the  patient  swallow  a  small  teaspoonful 
of  tartaric  acid  in  solution  and  immediately  afterwards 
a  similar  quantity  of  bicarbonate  of  soda.  The  evolu- 
tion of  carbonic  acid  gas  which  follows  distends  tlie 
organ.  The  patient  must  be  told  to  refrain^  if  he 
can,  from  eructation. 

(2)  Pass  a  stomach-tube  which  has  a  glass  mouth- 
piece. Then  distend  the  stomach  either  by  blowing 
down  the  tube  or  by  fitting  on  to  it  a  rubber  ball 
spray -producer,  and  so  pumping  in  air. 

Inflation  should  never  be  practised  if  there  has 
been  any  recent  bleeding  from  the  stomach  or  if  one 
has  reason  to  suspect  the  existence  of  a  gastric  ulcer. 
It  should  also  be  avoided  in  feeble  subjects  and  in 
those  in  whom  the  heart  is  in  any  way  embarrassed. 

Inspection  of  the  stomacti  region  is  included 
in  the  general  examination  of  the  abdomen.  If  dilated 
the  organ  may  possibly  be  seen  standing  out  even 
before  inflation.  It  may  form  a  tumour  in  any  part 
of  the  abdomen  except  the  upper  portion  of  the 
epigastric  region.  If  it  be  dislocated  downwards,  the 
outline  of  the  lesser  curvature  may  be  visible.  Peri- 
staltic movements  of  the  stomach  wall  have  already 
been  referred  to  (p.  53). 

Palpation  of  the  stoniaoh.— Note  if  there  be 


62  The  Stomach. 

any  tenderness  felt  on  palpating  the  stomach  and 
define  its  point  of  greatest  intensity.  Examine  for 
tumours.  The  commonest  of  these  is  a  pyloric  new 
growth.  Tumours  of  this  region  are  characterised  by 
their  great  mobility.  They  may  be  felt  in,  or  pushed 
into,  any  region  of  the  abdomen.  Lastly,  try  for 
splashing.  To  make  out  this,  sit  at  the  left  side  of 
the  patient  with  one  hand  over  the  left  lower  ribs 
behind  ;  with  the  other  placed  over  the  front  of  the 
stomach  make  short,  sudden,  dipping  movements.  If 
"splashing"  be  elicited  it  will  be  partly  heard  and 
partly  felt. 

Distinct  splashing  elicited  three  hours  after  a 
meal,  especially  if  it  can  be  made  out  below  the  level 
of  the  umbilicus,  is  very  suggestive  of  a  dilated 
stomach. 

Percussion  of  tlie  stomach. — Three  bound- 
aries of  the  stomach  can  be  made  out  by  percussion  : 
(1)  Between  stomach  and  lung;  (2)  between  stomach 
and  liver  ;  (3)  between  stomach  and  colon. 

The  last  is  that  which  it  is  most  important  to 
determine,  and  should  be  examined  first.  It  is  by 
no  means  always  easy  to  define  the  lower  border  of 
the  stomach  exactly.  This  is  because  the  transverse 
colon  may  give  an  almost  identical  note  with  it.  Use 
light  percussion.  The  "flicking"  method  succeeds 
very  well  here.  Begin  low  down  near  the  pubes  and 
percuss  upwards  just  to  the  left  of  the  middle  line. 
The  lower  border  of  the  stomach  should  be  reached 
about  a  finger's  breadth  above  the  umbilicus. 

The  limit  between  the  lower  edge  of  the  lung  and 
the  upper  part  of  the  stomach  is  made  out  in  a  similar 
way.  It  is  best  to  percuss  from  stomach  to  lung. 
The  usual  line  of  demarcation  between  the  two  runs 
in  a  slightly  arched  manner  from  the  sixth  costal  cart- 
ilage in  the  parasternal  line  to  the  ninth  in  the 
mid-axillary   line.     The   area   of  stomach   resonance 


Percussion.  63 

wliicli  is  bounded  above  by  this  line  and  l^y  tlio 
anterior  edge  of  the  spleen,  and  below  by  the  left 
costal     margin,    is    called    Traube's    space.       It 

covers  that  portion  of  the  stomach  which  is  in  direct 
contact  with  the  chest-wall.  We  have  seen  that  the 
fundus  of  the  stomach  extends  above  this  under  cover 
of  the  lung  as  high  as  the  fifth  rib  in  the  nipple  line. 
It  cannot,  however,  be  satisfactorily  percussed  out. 

The  demarcation  between  the  stomach  and  liver  is 
made  out  by  percussing  lightly  from  the  stomach 
towards  the  liver  margin.  It  is  not  of  much  im- 
portance. 

We  would  repeat  that  for  the  diagnosis  of  dilated 
stomach  the  position  of  the  great  curvature  is  of  most 
importance.  If  this  be  found  to  be  below  the  umbilicus, 
while  the  lesser  curvature  is  in  its  normal  position, 
then  the  existence  of  dilatation  is  certain.  It  is  con- 
firmed if  the  stomach  note  extends  much  across  the 
middle  line  towards  the  right. 

The  position  of  the  stomach-lung  and  stomach- 
liver  boundaries  depends  as  much  upon  the  condition 
of  the  lung  and  liver  as  upon  the  stomach  itself. 
Thus  in  fibroid  contraction  of  the  lung  more  of  the 
stomach  is  exposed  than  is  normal,  and  its  area  is 
therefore  apparently  increased.  Cirrhosis  of  the 
liver  may  produce  a  similar  apparent  extension  of 
stomach  area.  On  the  other  hand,  effusions  into  the 
pleura  or  enlargements  of  the  liver  cover  up  the 
stomach,  and  cause  a  diminution  in  its  area  of 
resonance.  Hence  in  the  former  condition  Traube's 
space  is  much  diminished  (see  p.  233).  The  possi- 
bility of  a  dislocation  of  the  whole  organ  downwards 
must  never  be  lost  sight  of.  In  such  a  case  the 
outline  of  the  lesser  curvature  may  often  be  seen 
standing  prominently  out,  especially  when  the  organ 
is  inflated.  If  the  distance  between  the  greater  and 
lesser  curvature  is  more  than  10  cm.,  dilatation  exists. 


64  TiiR  Stomach. 

Tiie    coiiibiiiecl   pereiisf^ioii— aiif^ciiltatioii 

iiietlioci  often  gives  valuable  aid  in  mapping  out 
the  stomach.  To  carry  it  out  proceed  as  follows  : — 
Place  the  end  of  a  wooden  stethoscope  over  the 
stomach,  either  somewhere  in  Traube's  area,  or, 
better,  in  the  angle  between  the  xiphoid  cartilage  and 
the  left  costal  margin.  Then  percuss  lightly  near 
the  stethoscope.  A  characteristic  note  is  heard. 
Then,  still  keeping  the  stethoscope  in  the  same 
situation,  start  percussing  near  the  pubes,  and  percuss 
ujD  towards  the  umbilicus  until  a  note  similar  to  that 
first  heard  is  made  out  again.  That  indicates  that 
the  edge  of  the  stomach  has  been  passed.  One  can 
now,  by  percussing  in  different  directions,  make  out 
the  limits  of  the  organ  all  round.  The  method 
depends  on  the  fact  that  the  aerial  vibrations  set 
up  under  the  percussing  finger  resound  all  through 
the  organ,  and  therefore  reach  the  stethoscope 
placed  over  any  part  of  it.  Previous  inflation  of 
the  organ  is  not  required.  Be  careful  not  to  use 
too  strong  a  percussion  stroke,  or  vibration  may  be 
set  up  in  adjoining  viscera. 

Auscultation  of  the  stomaeli  area  may 
detect  peritoneal  friction  over  it,  or  the  crackling 
due  to  the  bursting  of  fermentation  bubbles  in  the 
interior.  Heart  sounds  and  murmurs  are  sometimes 
heard  loudly  over  the  stomach  as  over  a  resonating 
chamber.  The  deglutition  sounds  are  of  no  diagnostic 
value. 

The  chemical  investiofation  of  the  stomach  is 
considered  in,  Section  lY.  (p.  76). 

The  Liver. 
Special    anatomy    (Plates  I.,  II.,  III.), — The 

liver  lies  chiefly  in  the  right  hypochondrium.  Its  left 
lobe  extends  across  the  epigastric  region,  but  does  not 
pass  more  than  two  inches  to  the  left  of  the  sternum. 


J8R0DII 


PLATE    1 1. -VISCERA   OF   THORAX   AND  ABDOMEN,  AS  SEEN  FROM 
BEHIND.    Scale  :  1  =  5-6.    (After  LuschM.) 

[To  face  p.  65 


The  Liver.  65 

Above,  the  liver  reaches  almost  to  the  nipple  ;  below 
it  extends  to  the  costal  margin.  The  lower  border 
passes  obliquely  upwards  from  the  ninth  right  to 
the  eighth  left  costal  cartilages,  crossing  the  middle 
line  somewhat  above  the  mid  point  between  the  base 
of  the  xiphoid  and  the  umbilicus. 

The  gall  bladder  is  situated  just  internally  to  the 
ninth  right  costal  cartilage  and  immediately  to  the 
outer  side  of  the  right  rectus  muscle. 

IiispcctioiB  of  the  liver  is  of  little  value. 
Any  visible  swelling,  fulness,  or  pulsation  should  be 
noted.  The  edge  of  the  liver  can  sometimes  be  seen 
when  the  organ  is  enlarged.  It  forms  a  sharp  line 
which  moves  up  and  down  with  respiration. 

Palpation  of  liver.— The  lower  edge  should 
first  be  felt  for.  In  order  to  do  this,  place  the  hand 
flatly  on  the  abdomen,  with  its  edge  towards  the  costal 
margin  and  just  to  the  outer  side  of  the  rectus 
muscle,  the  reason  for  going  so  far  out  being  to 
avoid  the  upper  septum  of  the  rectus  sheath,  which 
is  apt  to  be  mistaken  for  the  lower  edge  of  the  liver. 
Tlien  depress  the  edge  of  the  hand  slightly  so  as  to 
push  up  a  fold  of  skin,  and  ask  the  patient  to  take  a 
long  breath.  If  the  edge  of  the  liver  is  palpable, 
it  will  be  felt  to  ride  over  the  edge  of  the  hand. 
Trial,  of  course,  must  be  made  at  different  levels 
before  it  is  decided  that  the  edge  cannot  be  felt. 
The  edge  of  the  liver  cannot,  or  can  only  very  rarely, 
be  felt  in  health.  It  moves  down  from  two-fifths  to 
three-fifths  of  an  inch  with  inspiration.  The  character 
of  the  edge  should  also  be  noted — whether  it  is 
smooth  or  irregular,  thickened  or  sharp.  If  in  doubt 
whether  what  is  felt  be  really  the  liver  edge,  feel 
for  the  fissure  for  the  gall  bladder,  and,  towards 
the  middle  line,  for  that  produced  by  the  round 
ligament. 

The  surface  of  the  liver  in  the  epigastrium  should 


66 


The  Liver. 


then  be  felt  in  the  usual  way.  Any  tenderness 
should  be  noted,  and  whether  it  is  localised  or 
seneral.  The  character  of  the  surface  should  be 
made  out.  Is  it  smooth,  as  in  waxy  disease,  or 
nodular,  as  in  carcinoma  1  In  the  latter  condition 
the  centres  of  the  nodules  will  often  be  found  to 
be  umbilicated.  Care  must  be  taken  not  to  con- 
found little  irregularities  which  are  frequently 
present  in  the  upper  parts  of  the  recti  with  irregu- 
larities on  the  surface  of  the  liver.  Liver  friction 
(due  to  perihepatitis)  can  sometimes  be  felt.  It 
is  usually  best  made  out  over  the  posterior  surface 
of  the  organ  between  the  vertebrae  and  the  mid- 
axillary  line. 

Heaving  pulsation  of  the  whole  organ  can  best 
be  appreciated  by  placing  one  hand  over  the  lower 
right  ribs  behind  and  the  other  over  the  organ  in 
front. 

Percussion  of  the  livei*.—  The  following  table 
shows  the  normal  percussion  limits  of  the  liver 
(Fig.  20)  :- 


Mamillary 

Mid-.\xil- 

Scapular 

line. 

lary  line. 

line. 

Deep 

A 

4th  space. 

7th  space. 

9th  space. 

diilness. 

Blend 

Upper  J 

with 

limit. 

heart 

Superficial 

dulness. 

^   dulness. 

j 

6th  rib. 

Sth  rib. 

10th  rib. 

Hand's 

Costal  mar- 

Blends with 

Lower  limit. 

brea<lth 
below  base 
of  xiphoid. 

gin  or  some- 
what above 
or  below  it. 

10th  space. 

kidney 
dulness. 

Procedure, — The  patient  should  be  lying  down  in 
percussion  of  the  anterior  and  lateral  aspects ;  sitting 
up  or  standing  for  the  posterior  aspect. 

To  make  out  the  deep  dulness,  use  heavy  per- 
cussion—two fingers,  if  necessary.      Begin  high  up — 


Percussion.  67 

say  about  the  second  rib — so  as  to  get  a  good  lung 
note,  and  percuss  down  from  rib  to  rib  till  im- 
pairment is  detected.  Then  repeat  the  process, 
going  from  space  to  space  instead  of  from  rib  to  rib. 
Percuss  in  this  way  down  the  mammary,  mid-axillary, 
and  scapular  lines. 

The  upper  limit  of  liver  dulness  in  the  middle 
line  cannot  be  distinguished  from  the  heart  dulness. 
To  map  it  out,  draw  a  straight  line  from  the  apex 
beat  to  the  angle  where  the  right  edge  of  the 
heart  and  the  deep  liver  dulness  meet.  To  make 
out  the  upper  limit  of  superficial  dulness,  percuss 
lightly  down  the  same  lines.  The  upper  limit  of 
liver  dulness  forms  an  almost  horizontal  line  around 
the  chest. 

In  defining  the  lower  edge  of  the  liver,  use  very 
light  percussion,  and  pass  upwards.  The  "flicking" 
method  does  well.  Another  good  plan  is  to  percuss 
^vith  three  fingers  of  the  right  hand  held  in  a  row. 
Very  slight  degrees  of  dulness  can  often  be  more 
easily  detected  by  this  device. 

The  exact  position  of  the  lower  edge  of  the  liver 
is  extremely  variable.  Usually  it  coincides  with  the 
costal  margin  in  the  mammary  line.  It  may  be  con- 
siderably above  or  below  this,  however,  without  there 
being  any  pathological  change  in  the  organ.  Its 
position  in  the  middle  line  is  also  very  A^ariable. 
Asa  rule,  it  is  situated  about  a  hand's  breadth  below 
the  base  of  the  xiphoid. 

In  percussing  the  surface  of  the  liver  where  it 
is  not  covered  by  lung,  it  should  be  observed  that  the 
organ  has  a  certain  degree  of  resistance  or  resilience. 
The  normal  amount  of  this  can  only  be  learnt  by 
practice.  If  the  organ  be  enlarged  or  congested, 
its  resistance  to  percussion  is  increased  owing  to  its 
being  more  firmly  pressed  against  the  chest  wall. 

The  liver  may  be  displaced,  enlarged,  or  diminished. 


68  The  Liver. 

Displacement  may  be  either  upwards  or  down- 
wards. Upward  displacement  may  occur  from 
tumours,  etc.,  in  the  abdomen  pushing  the  liver  up. 
Downward  displacement  may  be  brought  about  by 
dilatation  of  the  right  ventricle  of  the  heart,  right 
pleural  effusion  or  emphysema  of  the  lungs,  or,  more 
rarely,  by  new  growths  below  the  diaphragm.  When 
the  liver  is  dislocated  downwards,  the  rounded  upper 
surface  of  the  left,  and  part  of  the  right,  lobe  can 
usually  be  made  out  crossing  the  epigastrium.  A 
displaced  liver  also  does  not  move  freely  with  respira- 
tion, while  a  liver  which  is  merely  enlarged  does. 

One  must  distinguish  between  real  enlargements 
and  diminutions  of  the  liver  and  those  which  are 
apparent  only. 

Thus  enlargement  of  the  liver  may  be  simulated 
by  consolidations  of  the  base  of  the  right  lung,  or 
by  effusion  into  the  right  pleura.  Downward  en- 
largement may  be  simulated  by  accumulation  of  faeces 
in  the  transverse  colon. 

Real  enlargement  may  be  due  to  waxy  disease, 
congestion,  fatty  infiltration,  hypertrophic  cirrhosis, 
new  growths,  leucocythsemia,  abscess,  or  hydatids. 

A  hydatid  cyst  in  the  liver  often  produces 
an  enlargement  of  the  organ  upwards  rather  than 
downwards. 

Diminution  of  the  liver  may  be  simulated  by 
the  organ  being  covered  up  by  an  emphysematous 
lung,  or  by  the  colon  passing  up  between  it  and 
the  abdominal  wall.  The  latter  is  a  rare  condition. 
It  should  be  suspected  if  the  lower  limit  of  liver 
dulness  varies  very  much  at  different  points.  Real 
diminution  occurs  in  cirrhosis  and  in  acute  yellow 
atrophy. 

The  gall  bladder  is  examined  by  palpation 
and  percussion.  It  cannot  be  felt  unless  distended. 
It   may    then  form    a    smooth,  pear-shaped    tumour, 


noDtt 


PLATE  III.— VISCEEA  FROM  THE  SIDE.  The  lower  limit  of  the  lung  is 
shown  both  after  full  inspiration  and  full  expiration.  The  line  of  reflexion 
of  the  pleural  sac  is  also  shown.    Scale :  1  =  5*6.     (After  Luschka.) 

[To  fcice  p.  69. 


Anatomy  of  Spleen. 


69 


situated  just  to  the  outer  edge  of  the  right  rectus 
muscle.  It  can  be  moved  freely  from  side  to  side 
round  a  point  opposite  to  the  ninth  costal  cartilage.  It 
also  moves  with  respiration.  Sometimes  gall  stones 
can  be  felt  in  it.  If  there  be  many  of  these,  they 
produce  on  palpation  a  sensation  resembling  that 
produced  on  feeling  a  bag  of  nuts. 

On  percussion,  a  distended  gall  bladder  forms 
a  dull  area,  projecting  out 
from  the  liver  dulness  to- 
wards the  umbilicus,  but 
usually  continuous  with  it. 
Sometimes,  however,  the 
transverse  colon  comes  to 
lie  across  the  neck  of  the 
gall  bladder,  so  as  to  separate 
it  from  the  liver.  When 
this  occurs,  diagnosis  of  the 
tumour  is  apt  to  give  trouble. 
To  this  point  we  shall  recur 
when  we  come  to  the  ex- 
amination of  the  right  kidney 
(p.  73). 

Fig.  6. — Enlargement  of  spleen. 

The  Spleen. 

Special  anatomy  (Plates  II.  and  III.). — The 
spleen  lies  in  the  left  hypochondrium.  It  is  bounded 
above  by  lung,  elsewhere  by  stomach  and  intestine. 
Its  lower  end  rests  upon  the  costo-colic  fold  of  peri- 
toneum. It  lies  along  the  ninth,  tenth,  and  eleventh 
ribs,  being  partially  separated  from  them  by  the 
diaphragm  and  lower  edge  of  the  left  lung.  Its 
upper  end  is  opposite  the  ninth  dorsal  spine,  and 
reaches  to  about  \\  in.  from  the  middle  line.  Its 
lower  end  comes  as  far  forward  as  the  mid- axillary 
line. 

Iiispeetioii  of  tlie  spleen. — If  much  enlarged, 


7^  The  Spleen. 

the  spleen  may  form  a  visible  tumour  in  the  left  side 
of  the  abdomen,  which  moves  with  respiration  (Fig.  6). 

Palpation  of  tlie  ispleen. — This  is  really  the 
most  important  method  t)f  investigating  the  spleen. 
If  one  can  exclude  dislocation,  then  a  spleen  which 
is  palpable  may  safely  be  pronounced  to  be  enlarged, 
and  it  is  never  safe  to  diao^nose  enlargement  of  the 
spleen  unless  it  is  palpable. 

There  are  two  methods  of  feeling  for  the  spleen — 

('1)  Stand  or  sit  at  the  left  side  of  the  patient 
as  he  lies  on  his  back.  Keep  the  hand  flat  on 
the  abdomen,  and  depress  the  fingers  a  little,  so  as 
to  push  up  a  fold  of  skin  near  the  left  costal  margin 
opposite  the  tenth  cartilage,  and  get  the  patient 
to  take  a  long  breath.  The  edge  of  the  enlarged 
spleen  will  be  felt  to  come  up  against  the  finger  tips^ 
and  to  ride  over  them,  as  it  were. 

(2)  Go  to  the  right  side  of  the  patient.  Place 
the  fingers  of  one  hand  behind  in  the  space  between 
the  ends  of  the  tenth  and  eleventh  ribs.  Place  the 
other  hand  over  the  left  hypochondrium,  with  the 
fingers  slightly  tucked  in  under  the  edge  of  the  costal 
arch.  With  the  posterior  hand  tilt  the  spleen  for- 
wards while  the  patient  inspires.  The  edge  of  the 
organ  will  then  be  felt  against  the  fingers  of  the  other 
hand. 

The  edge  of  the  spleen  is  sharp  and  usually  quite 
smooth.  Notches  can  often  be  felt  in  it,  but  by 
no  means  invariably.  It  is  important  to  note  (1) 
that  the  anterior  border  of  an  enlarged  spleen  is 
always  directed  downwards  and  inwards,  and  (2) 
that  there  is  always  a  slight  space  between  the 
posterior  edge  of  the  spleen  and  the  erector  spinse, 
into  which  the  fingers  can  be  dipped.  Occasionally 
the  spleen  enlarges  upwards  only.  This  may  happen 
where  the  costo-colic  fold  is  abnormally  well  de- 
veloped, and  keeps  the  organ  up.     For  the  detection 


Percussion.  7 1 

of   such    a    erudition,    one    must    have    recourse    to 
percussion. 

Percussion  of  the  spleen.  —  The  anterior 
part  of  the  spleen  can  be  defined  whilst  the  patient  is 
lying  on  his  back.  For  the  posterior  part  one  of  two 
positions  is  advisable — he  may  either  sit  up,  with  his 
left  hand  supported  on  the  top  of  his  head,  or  he  may 
be  semi-prone,  restino^  chiefly  on  the  right  scapula, 
with  the  left  arm  behind  the  head.  He  should  not  be 
altogether  on  his  right  side,  else  the  spleen  falls  away 
too  much  from  the  surface  of  the  body.  One  should 
be  careful  to  percuss  only  in  the  intervals  of  respiration. 

The  limits  of  the  normal  spleen  cannot  always  be 
defined  by  percussion.  It  may  be  borne  away  so  much 
from  the  surface,  owing  to  extreme  arching  of  the 
diaphragm,  or  it  may  be  so  covered  up  by  lung,  that 
it  is  impossible  to  be  sure  of  its  exact  limits. 

Procedure. — Define  the  anterior  edge  by  percussing 
lightly  along  the  tenth  rib,  beginning  near  the  costal 
edge.  The  splenic  dulness  (absolute)  should  be  reached 
at  the  mid-axillary  line. 

The  lower  edge  is  defined  by  percussing  lightly 
upwards  along  the  posterior  axillary  line  or  slightly 
behind  it.  The  lower  edge  of  the  spleen  should  be 
reached  about  the  lower  border  of  the  eleventh  rib. 

To  make  out  the  upper  and  posterior  borders^  heavy 
percussion  is  required.  Percuss  verticilly  downwards 
about  midway  between  the  posterior  axillary  and 
scapular  lines,  beginning  at  about  the  level  of  the 
angle  of  the  scapula.  The  lung  note  will  become 
impaired  at  the  upper  edge  of  the  ninth  rib,  indicating 
that  the  upper  limit  of  the  spleen  has  been  reached. 

The  2^osterior  border  is  defined  by  percussing 
along  the  tenth  rib,  beginning  near  the  middle  line. 
The  splenic  dulness  is  reached  at  about  IJ  in.  from 
the  vertebral  spines.  This  border  is  not  always  easy 
to  make  out. 


72  The  Kidneys. 

By  joining  together  the  different  points  defined 
above,  an  oval  area  will  be  mapped  out,  which 
measures  about  3  in.  in  its  long  diameter  and  2  in. 
transversely. 

Extension  of  s-plenic  dulness  may  be  simulated  by 
effusions  into  the  left  pleura,  or  consolidation  of  the 
base  of  the  left  lung ;  by  the  presence  of  fluid  in  the 
stomach,  or  of  fsecal  accumulation  in  the  colon. 

Enlargement  of  the  sixteen  occurs  in  acute  fever 
(especially  typhoid),  in  waxy  disease,  malaria,  various 
blood  affections,  etc. 

Aiiisiciiltatioii  over  tlie  spleen  may  be  prac- 
tised to  detect  the  existence  of  friction.  The  latter 
occurs  in  perisplenitis  and  over  the  surface  of  splenic 
infarcts. 

The   Kidneys. 

Special  anatomy  (Plate  II.). — Each  kidney 
lies  partly  in  the  epigastric,  partly  in  the  hypochon- 
driac region.  The  right  kidney  lies  partly  in  the 
lumbar  region  as  well.  As  regards  their  relation  to 
the  anterior  abdominal  wall,  the  kidneys  are  higher 
up  than  one  is  apt  to  suppose.  The  lower  end  of  the 
right  kidney  is  fully  1  in.  above  the  umbilicus,  the 
left  is  about  \  in.  higher.  The  lower  end  of  each  is 
about  3  in.  from  the  middle  line. 

As  regards  their  posterior  relations,  about  one- 
third  of  each  kidney  lies  above  the  last  rib.  The 
upper  end  of  the  right  kidney  is  at  the  level  of  the 
eleventh  dorsal  spine,  whilst  its  lower  end  reaches 
to  about  1  in.  above  the  iliac  crest.  The  left  kidney 
is  about  \  in.  higher. 

Palpation  of  the  kidney. 

Procedure. — Sit  beside  the  patient  on  the  side 
to  be  examined.  Place  one  hand  immediately  below 
the  last  rib  behind,  the  other  over  the  lower  part 
of  the  hypochondriac  region  in  front.     See  that  the 


Palpation. 


73 


patient's  knees  are  drawn  up  and  his  shoulders  raised. 
Ask  him  to  take  a  long  breath,  and  follow  up  the 
receding  abdominal  wall  during  expiration  with  the 
fingers  of  the  hand  in  front.  The  lower  part  of  the 
kidney  can  then  be  felt  even  in  health  (provided  the 
patient  be  not  too  fat)  between  the  two  hands. 

The  kidney  moves  very  slightly  with  respiration. 
An  exaggeration  of  this  normal  mobility,  so  that  the 
organ  slips  up  and  down  like  a  pea  in  a  pod,  con- 
constitutes  "  ^^zo^Ja^^e  kidney. ^^  This  must  be  distin- 
guished from  '•'■  jioating  kidney^''  in  which  the  organ 
has  a  mesentery  and  moves  about 
in  all  directions. 

A  floating  right  kidney  is  very 
apt  to  be  mistaken  for  a  distended 
gall  bladder  and  vice  versd.  The 
shape,  size,  and  consistence  of  the 
tumour  may  be  apparently  iden- 
tical in  the  two  cases.  One  point 
of  distinction  is  that  while  a  dis- 
tended gall  bladder  can  be  tem- 
porarily pushed  back  from  the 
abdominal  wall,  yet  it  always 
tends  to  spring  forward  again.  It 
is  therefore  always  in  evidence. 
It  is  not  so  with  a  floating  kidney ; 
the  latter  disappears  often  for  a 
time,  and  can  only  with  difficulty 
be  got  hold  of  again.  Another 
point  of  distinction  is  that  a  kidney 
can  be  pushed  down  towards  the  pelvis  and  held  there 
even  during  forcible  expiration,  whilst  the  gall  bladder 
moves  upwards  again  during  the  expiratory  act.  The 
different  relation  of  the  colon  to  the  kidney  and  to 
the  gall  bladder  should  also  be  remembered. 

An  enlarged  left  kidney  may  be  mistaken  for  the 
spleen.     The  points  of  distinction  are :  (1)  That  the 


Fig.  7.— Showing  colon 
crossing  a  tumour  of 
the  kidney.  {After 
Sahli.) 


74  The  Intestines. 

spleen  has  a  sharp  edge.  The  edge  of  the  kidney  is 
ahcays  rounded.  The  existence  of  a  sharp  edge  in 
any  abdominal  tumour  excludes  the  kidney  at  once. 
(2)  There  is  no  space  between  the  posterior  border 
of  the  kidney  and  the  erector  spin?e,  as  there  is  in  the 
case  of  the  spleen ;  and  (3)  the  colon  lies  between 
the  kidney  and  the  anterior  abdominal  wall,  but  not 
over  the  spleen  (Fig.  7). 

It  is  impossible  to  determine  the  size  of  the  kidney 
by  means  of  percussion. 

An  enlarged  kidney  tends  to  bulge  forwards. 
Perinephric  abscesses^  etc.,  bulge  backwards. 

The  Intestines. 

Special  anatomy. — The  small  intestine  occupies 
chiefly  the  umbilical  and  hypogastric  regions ;  the 
large  intestine,  the  peripheral  zone  of  the  abdomen. 
The  ileum  joins  the  colon  at  a  point  2  in.  internal 
to,  and  somewhat  above,  the  right  anterior  superior 
iliac  spine.  The  apex  of  the  cjecum  corresponds  to 
a  point  a  little  to  the  inner  side  of  the  middle  of 
Poupart's  ligament.  The  vermiform  appendix  lies 
opposite  a  point  midway  between  the  left  anterior 
superior  iliac  spine  and  the  umbilicus.  This  is  some- 
times called  McBurney^s  point. 

The  splenic  flexure  of  the  colon  lies  behind  the 
stomach,  the  hepatic  lies  under  cover  of  the  liver. 
The  former  is  at  a  somewhat  higher  level  than  the 
latter.  The  transverse  colon  passes  across  the  abdo- 
men in  a  slightly  curved  direction,  the  lower  part 
of  the  curve  reaching  to  about  the  umbilicus. 

Examination  of  the  intestines  by  inspection 
and  palpation  has  already  been  described  under 
the  general  examination  of  the  abdomen  (p.  51). 

Percnssion  of  the  intestines.  —  The  notes 
yielded  by  the  small  and  large  intestine  cannot  be  satis- 
factorily discriminated.     The    combined    percussion- 


Rectal  Examination.  75 

auscultation  method  can  be  used  to  map  out  the  colon 
in  the  same  way  as  was  described  for  the  stomach. 
One  should  place  the  stethoscope  near  the  splenic  or 
hepatic  flexure,  and  percuss  close  to  it.  Then  begin 
at  what  is  presumably  beyond  the  periphery  of  the 
gut,  and  percuss  towards  the  stethoscope  till  the 
characteristic  note  is  recognised. 

Rectal  examination. — Place  the  patient  in  a 
good  light  and  in  the  semi-prone  position — i.e.  resting 
on  the  left  breast  with  the  right  thigh  and  knee  well 
drawn  up,  the  inner  aspect  of  the  right  knee  rest- 
ing on  the  couch.  Draw  aside  the  glutei  and  inspect 
the  region  of  the  anus,  noting  the  presence  of  any 
eruption,  of  external  haemorrhoids,  etc.  Smear  the 
right  forefinger  with  vaseline  and  fill  the  nail  with 
soap.  Pass  the  finger  slowly  and  gently  through  the 
anus,  directing  it  slightly  forwards  at  first.  Note  the 
degree  of  resistance  offered  by  the  sphincter;  this  shows 
whether  the  latter  is  normal,  spasmodic,  or  relaxed. 

Once  the  anal  canal  is  passed,  direct  the  finger 
slightly  backwards  and  upwards,  asking  the  patient 
to  bear  down  a  little  at  the  same  time.  The  finger 
can  then  be  swept  round  and  the  whole  inner  surface 
of  the  rectum  explored. 

Two  folds  of  mucous  membrane  will  be  encoun- 
tered (Houston's  folds),  one  opposite  the  prostate  in 
front,  the  other  higher  up,  near  the  middle  of  the 
sacrum,  and  passing  in  from  the  left  side.  The 
prostate  will  be  felt  projecting  into  the  rectum 
in  the  male,  and  above  it  is  the  trigone  of  the 
bladder  flanked  by  the  seminal  vesicles ;  below  it 
is  the  membranous  urethra.  In  the  female  the 
cervix  uteri  will  be  felt  projecting  back  in  the 
form  of  a  hard  knob.  The  mucous  membrane  must 
be  examined  for  polypi,  ulcers,  etc.  It  must  be 
remembered  that  haemorrhoids  are  not  palpable. 
The   presence  of  scybala   or  foreign   bodies    can  be 


76       Chemical  Investigation  of  Stomach. 

determined,  and  the  existence  of  any  tumour,  either 
in  the  bowel  or  pressing  upon  it,  can  be  made  out. 
If  the  lymphatic  glands  which  lie  in  the  hollow  of  the 
sacrum  are  enlarged,  they  can  be  felt. 

SECTION  IV.— CHEMICAL  INVESTIGATION 
OF  THE  STOMACH  CONTENTS. 

The  object  of  this  is  to  test  the  digestive  and  motor 
power  of  the  stomach. 

A  "  test  meal "  is  given,  and  the  stomach  contents 
are  withdrawn,  after  a  stated  interval,  and  examined. 
The  meal  may  be  either  a  test  breakfast  (Ewald)  or  a 
test  dinner  (Leube  and  Riegel).  The  breakfast  con- 
sists of  a  slice  of  dry  bread  and  a  tumblerful  of  water 
or  very  weak  tea.  The  dinner  consists  of  14  ozs. 
of  soup,  2  ozs.  of  mince^  and  2  ozs.  of  bread.  The 
contents  are  withdrawn  after  the  lapse  of  one  hour 
in  the  case  of  the  breakfast,  or  after  four  hours  if 
a  dinner  has  been  given. 

Method  of  withdrawing  contents.  —  Pass  the 
stomach  tube  as  described  at  p.  47.  Fix  a  funnel  to 
the  end  of  it,  and  ask  the  patient  to  cough  or  strain 
(as  in  retching)  two  or  three  times.  This  usually 
suffices  to  drive  the  stomach  contents  up  into  the 
funnel.  Should  it  fail,  one  can  either  (1)  take  a 
rubber-ball  syringe,  such  as  is  used  for  giving  a 
nutrient  enema,  squeeze  it  empty,  fix  it  to  the  end 
of  tlie  stomach  tube,  and  then  allow  it  to  expand, 
so  sucking  up  the  contents  (a  stout  Politzer's  bag 
may  be  used  similarly) ;  or  (2)  one  can  connect  the 
end  of  the  stomach  tube  to  a  partially  exhausted 
aspirating  bottle,  and  exert  suction  in  that  way. 

When  the  stomach  contents  have  been  obtained 
they  should  be  allowed  to  settle  in  a  tall  jar,  after 
which  one  can  proceed  to  examine  them.  The  follow- 
ing points  have  to  be  ascertained  : — 


Acidity  of  Contents.  jy 

1.  Are  the  contents  acid! — Test  with  litmus 

paper. 

2.  Is  the  acidity  due  to  free  acid  or  to  acid 
phospliates  1 — This  may  be  tested  in  two  ways  : — 

(a)  Dip  in  a  piece  of  Congo  red  test  paper. 
(Appendix,  8.)  Free  acids  turn  this  blue;  acid 
phosphates  do  not. 

(b)  Take  5  cc.  or  so  of  the  fluid  in  a  test  tube, 
and  add  to  it  a  pinch  of  calcium  carbonate.  If  eflfer- 
vescence  occurs,  free  acid  is  present.  Filter.  If  the 
filtrate  still  retains  its  acidity,  then  acid  phosphates 
are  present. 

This  test  depends  upon  the  fact  that  free  acid 
is  neutrahsed  by  calcium  carbonate,  while  acid  phos- 
phates are  not. 

3.  Ho\i'  acid  are  the  contents  I — i.e.  total 
acidity. — Take  20  cc.  of  the  original  fluid  (un- 
filtered),  add  280  cc.  of  distilled  water,  and  shake  up 
thoroughly,  so  as  to  break  up  any  particles.  Divide 
into  two  equal  portions  of  150  cc.  each,  and  add 
to  each  a  few  drops  of  phenol-phthalein  solution. 
Place  the  two  portions  in  separate  flasks,  and  titrate 
one  with  decinormal  soda  solution,  keeping  the 
other  as  a  standard.  Stop  running  in  the  soda 
whenever  the  least  trace  of  flesh  colour  appears 
in  the  flask.  This  can  best  be  appreciated  by  holding 
the  two  flasks  alongside  each  other  against  a  white 
surface.  The  process  may  then  be  repeated  with 
the  other  flask,  and  the  results  compared. 

The  result  may  be  stated  in  one  of  two  ways  :  (1) 
Directly,  the  number  of  cc.  of  decinormal  soda  solution 
required  to  neutralise  100  cc.  of  the  stomach  con- 
tents, being  taken  as  the  "acidity" — e.g.  if  10  cc. 
of  the  stomach  contents  be  titrated,  and  5  cc,  of 
decinormal  soda  run  in  before  a  pink  tinge  is 
produced,  then  50  cc.  of  soda  would  be  required  for 
100   cc.  of   the   fluid,   and   the   acidity  is    50.      The 


78      Chemical  Investigation  of  Stomach. 

normal  acidity  of  stomach  contents  varies  from  30 
to  70. 

(2)  One  may  express  the  result  in  terms  of  HCl. 
Thus  one  litre  of  decinormal  soda  is  required  to 
neutralise  3 -65  grms.  of  HCl.  If,  therefore,  100  cc. 
of  stomach  contents  require  50  cc.  of  soda  to  neutralise 
them,  then  the  acidity  of  the  100  cc.  is  equal  to  that 
of  0'18  grm.  HCl. — that  is  to  say,  the  acidity  is 
0*18  per  cent  The  normal  total  acidity  in  terms  of 
HCl.  is  about  0-2  per  cent. 

4.  Is  the  free  acid  present  mineral  {i.e. 
HCl.),   or  org-anic  {i.e.  lactic,  acetic,   butyric),  or 

botii  \ 

Gunzhurg's  test  for  free  HCl. — Place  ten  drops  of 
the  stomach  contents  in  a  porcelain  capsule,  add 
an  equal  quantity  of  the  phloroglucin  and  vanillin 
solution  (Appendix,  5).  Heat  gently,  taking  care  to 
avoid  charring.  If  free  hydrochloric  acid  is  present 
a  pink  colour  appears,  usually  at  the  periphery  of 
the  dried  fluid. 

The  reaction  is  only  given  by  free  hydrochloric 
acid.  The  combined  acid  and  organic  acids  do  not 
yield  it. 

Boas' s  7'esorcin  reagent  (Appendix,  6)  may  be  used 
similarly.      It  gives  a  purplish  colour. 

Tests  for  organic  acids. — It  is  best  first  to  dissolve 
these  out  by  means  of  ether.  Shake  up  10  cc. 
of  the  fluid  with  50  cc.  of  ether  very  thoroughly 
in  a  separation  funnel  or  tall  cylinder.  Pour  off 
the  ether.  Divide  the  ethereal  extract  into  two 
equal  portions,  and  place  these  in  wide  beakers. 
Set  one  in  hot  water ;  allow  the  other  to  evaporate 
slowly  at  the  temperature  of  the  room.  In  the 
former  all  the  ether  will  soon  have  disappeared. 
Dissolve  the  residue  in  about  5  cc.  of  water.  Take 
some  of  Uffelmann's  reagent  (Appendix,  7)  in  a  test 
tube,    and   add    to   it   a   few   drops   of    the   watery 


Tests  for   Organic  Acids.  79 

solution.     If   the   blue   solution    changes   to    yellow, 
lactic  acid  is  present. 

The  residue  of  the  second  beaker  is  used  to  test 
for  acetic  and  butyric  acids.  These,  being  volatile, 
would  be  driven  off  unless  the  ether  had  been 
evaporated  at  a  low  temperature.  Dissolve  the 
residue  in  a  little  water.  Neutralise  part  with  a 
little  carbonate  of  soda,  and  add  to  it  some  very 
dilute  perchloride  of  iron  solution.  A  claret-red 
colour  indicates  the  presence  of  acetic  acid.  To 
the  other  part  of  the  solution  of  the  residue  add 
a  small  fragment  of  calcium  chloride.  If  oily 
drops  appear  on  the  surface,  butyric  acid  is 
present. 

Acetic  acid  can  also  be  recognised  by  the  odour 
of  vinegar ;  butyric  acid  by  its  characteristically 
rancid  smell. 

In  carrying  out  the  above  tests,  it  is  well  to 
filter  the  stomach  contents  first  through  fine  muslin, 
and  to  use  only  the  filtrate. 

5.  Are  albtiiiioses  present  1 — Place  in  a  test 
tube  two  or  three  drops  of  a  10  per  cent,  solution 
of  sulphate  of  copper.  Invert  the  test  tube  so  that 
most  of  the  solution  runs  out  again.  As  much  will 
adhere  to  the  sides  as  is  required  for  the  test. 

Neutralise  a  little  of  the  filtered  stomach  con- 
tents, and  add  about  1  in.  of  the  fluid  to  the 
copper  solution.  Then  add  about  an  equal  amount  of 
caustic  soda  solution  (10  per  cent.).  If  albumoses 
are  present,  a  reddish  or  pinkish  colour  is  produced 
(biuret  reaction). 

The  presence  of  albumoses  proves  the  presence  of 
pepsin  in  the  gastric  juice.  In  the  absence  of 
albumoses,  pepsin  can  be  tested  for  by  its  digestive 
action  on  egg  albumen.  Hard-boiled  white  of  egg 
— preserved,  if  necessary,  in  glycerine — is  taken, 
and   small   pieces    of   it  punched   out   with    a   cork 


8o      Chemical  Investigation  of  Stomach. 

borer,  A  small  piece  is  placed  in  a  test  tube,  which 
is  then  half  filled  with  filtered  stomach  contents. 
If  the  filtrate  be  neutral  or  only  feebly  acid,  its 
acidity  must  be  increased  by  adding  an  equal  quantity 
of  0*8  per  cent.  HCl.  In  another  test  tube  is 
placed  a  similar  piece  of  egg  albumen.  To  this 
is  added  0*25  per  cent,  solution  of  HCl.  and  four 
drops  of  liquor  pepticus.  Both  tubes  are  put  in 
a  warm  place  for  an  hour,  and  the  effect  of  the 
two  fluids  on  the  ^gg  albumen  is  compared.  In  this 
way  a  comparison  is  arrived  at  between  the  activity 
of  the  fluid  under  examination  and  that  of  normal 
gastric  juice. 

Product  of  test  breakfast  in  health. — If 
a  test  breakfast  be  given  to  a  healthy  person 
and  the  contents  removed  one  hour  afterwards, 
it  will  be  found  that  20  cc.  to  40  cc.  of  fluid  are 
obtained.  This  is  transparent,  sbraw-coloured,  of 
an  acidity  equal  to  that  of  0*2  per  cent,  or  so  HCl.  ; 
it  contains  free  hydrochloric  but  no  organic  acid. 
Albumoses  are  present. 

In  some  functional  disorders  of  the  stomach  the 
total  acidity  of  the  contents  is  increased,  rising 
above  that  of  0-2  per  cent.  HCl.  Sometimes  no  free 
HCl.  is  found.  In  cases  of  malignant  disease  of 
the  stomach  the  absence  of  HCL  is  of  sufficient 
constancy  to  be  of  diagnostic  value.  The  presence 
of  organic  acids  is  an  indication  of  the  existence  of 
abnormal  fermentative  processes  in  the  stomach. 

The  absorptive  po\i^er  of  the  stomach  cannot 
be  satisfactorily  tested. 

The  motor  povi^er  is  best  tested  by  means  of  a 
test  dinner.  Seven  hours  after  such  a  dinner  the 
stomach  should  contain  no  food,  and  its  contents 
should  be  neutral.  '  If  expulsion  of  the  contents  has 
not  been  active  the  fluid  withdrawn  will  have  an 
acid  reaction,  and  will  show  the  presence  of  albumoses. 


The   Vomit.  8i 

The  presence  of  large  lumps  or  fragments  indicates 
enfeeblement  of  the  churning  power. 

SECTION    v.— EXAMINATION    OF    THE 
VOMIT. 

1.  :\ake<l-eye  characters. — The  general 
character  of  the  vomit  varies  greatly  of  course, 
with  the  nature  of  the  food  which  has  been  taken. 
In  dilatation  of  the  stomach  the  vomit  is  apt  to  be 
very  copious,  sour-smelling,  and  after  standing 
exhibits  a  froth  on  the  surface.  Bilious  vomit  is 
yellow  or  green  in  colour ;  /cecal  vomit  presents  a 
very  similar  appearance,  but  is  distinguished  by  its 
fB3cal  odour  and  by  its  neutral  or  alkaline  reaction. 
The  presence  of  much  mucus  gives  to  the  vomit  a 
viscid  consistence.  The  appearance  of  the  vomit 
in  hsematemesis  varies.  If  the  bleeding  be  very 
copious,  the  vomit  may  present  the  appearance  of 
pure  blood  and  may  contain  clots.  Such  bleeding 
may  proceed  from  a  gastric  ulcer  or  from  varicose 
oesophageal  veins.  More  commonly  the  blood  is 
altered  in  colour  by  being  retained  for  some  time  in 
contact  with  the  gastric  juice.  Thus  it  may  be 
blackish  in  colour  or  dark  brown.  The  latter  appear- 
ance is  due  to  the  conversion  of  haemoglobin  into 
haematin.  The  altered  blood  gives  to  the  vomit  an 
appearance  often  compared  to  that  of  coffee  grounds 
or  hare  soup.  It  should  be  borne  in  mind  that  the 
taking  of  preparations  of  iron  or  red  wines  may 
produce  a  very  similar  appearance  in  the  vomit. 
Yomit  which  contains  dark  green  bile  may  resemble 
very  closely  vomit  which  contains  blood.  On  dilut- 
ing with  water,  however,  the  green  colour  of  the  bile 
becomes  more  apparent,  while  blood  remains  dark. 

2.       Chemical    examinatioii. — The      vomit 
should  be  filtered  through  fine  muslin.     The  filtrate 

G 


82  Examination  of  Vomit. 

can  then  be  examined,  if  desired,  in  the  manner 
already   described  for   the  stomach  contents. 

Bile  can  be  detected  by  Gmelin's  test  (p.  320). 
For  the  chemical  detection  of  l>lood  in  the  vomit  the 
guaiac  test  is  not  satisfactory.  It  is  better  to  take  up 
some  of  the  brown  deposit  with  a  pipette,  to  place  it  in 
a  porcelain  capsule,  and  add  a  pinch  of  powdered  chlo- 
rate of  potash  and  a  few  drops  of  strong  hydrochloric 
acid.  Heat  till  dissolved.  Cool  and  add  a  few  drops 
of  ferrocyanide  of  potash  solution.  A  blue  colour 
indicates  that  blood  is  present.  The  reaction  is  due 
to  the  iron  contained  in  the  blood  pigment.  If  the 
patient  has  been  taking  iron  the  test  is,  of  course, 
inapplicable.  In  such  a  case  some  of  the  deposit 
should  be  digested  with  caustic  potash,  filtered,  and 
the  solution  examined  for  the  spectrum  of  alkaline 
hsematin,  or  the  deposit  may  be  subjected  to  Teich- 
mann's  test  (Appendix,  19).  To  confirm  the  test, 
add  to  the  alkaline  hsematin  solution  a  few  drops 
of  sulphide  of  ammonium,  which  converts  it  into 
hsemochromogen.  The  spectrum  of  the  latter  is 
identified  by  its  possessing  two  bands,  one,  narrow 
and  dark,  in  the  yellow  between  D  and  E,  the  other, 
broader  and  less  dark,  at  the  junction  of  the  yellow 
and  green  between  the  lines  E  and  b  (Fig.  63). 

3.  Microscopic  examination  (Fig.  8). — Take 
up  some  of  the  deposit  which  adheres  to  the  muslin, 
spread  it  out  on  a  slide,  and  examine  either  directly 
or  in  a  drop  of  salt  solution. 

Various  particles  derived  from  the  food  may  be 
recognised.  Muscle  fibres  by  their  transverse  striae. 
Starch  granules  by  their  concentric  lines  and  the  fact 
that  a  drop  of  very  dilute  iodine  solution  turns  them 
blue.  Elastic  fibres  by  their  double  contour  and  bold 
curves.     Fatty  2^aQ'ticles  by  their  high  refractility. 

Various  vegetable  parasites  may  be  present. 
The  most   important  are  the  sarcina   ventriculi 


Microscopic  Cha racters. 


83 


(a  large    micrococcus)    and    the  yeast  fuiig'i.     The 

former  can  h^  recognised  ]:)y  their  forming  small 
cubical  packets  of  cells  resembling  miniature  bales 
of  wool ;  the  latter  consist  of  round  or  oval  cells  in 
chains  or  clusters.  They  are  usually  about  the  size 
of  white  blood  corpuscles. 

The  addition  of  a  little  very  dilute  iodine  solution 


Fig.  S. — Microscopical  view  of  vomited  matter. 


n,  vegetal  lie  cells  ;  h.  epithelial  cells  ;  c,  starch  granule  ;  d,  oil  glolmle ;  e,  muscle 
'  fibre;  /,  sarcina  ventriculi ;  g,  torula. 

to  the  vomited  matter  may  render  the  detection  of 
sarcinse  more  easy.  The  iodine  stains  them  a  deep 
mahogany  brown. 

Permanent  preparations  of  these  fungi  may  be 
made  by  spreading  out  some  of  the  deposit  in  a  thin 
layer  on  a  cover  glass  and  drying  over  a  flame.  The 
best  stain  for  sarcinse  is  an  extremely  dilute — almost 
transparent — solution  of  gentian  violet.  Stain  for  a 
minute  or  two.  Bismarck  brown  also  gives  good 
results ;  stain  very  briefly.  For  yeasts  use  a  2  per 
cent,  solution  of  methylen  blue,  and  stain  for  half  a 


84  Examination  of  Falces, 

minute.     Wash  in  water  in  both  cases,  dry  between 
filter  papers,  and  mount  in  balsam. 

SECTION  VI.— EXAMINATION  OF  F^CES. 

1.  Naked  eye. 

The  following  points  should  be  attended  to  : — 
{«)  Amount  of  the  daily  stools ; 

(b)  Their  colour ; 

(c)  Their  odour  ; 

(c/)  Their  consistence  and  form  ; 

(e)  The  presence  of  any  abnormal  ingredients. 

As  regards  amoimt,  it  is  usually  sufficient  to 
state  whether  the  stools  are  copious  or  scanty.  The 
average  daily  amount  of  f?eces  in  health  is  120-1 80  grms. 
(about  4  ozs.). 

The  colour  of  normal  faeces  is  partly  due  to 
urobilin,  partly  to  chlorophyll  and  other  pigments. 
The  presence  of  unaltered  bile  pigment  is  always 
abnormal,  and  may  be  due  to  increased  rapidity  of 
peristalsis.  Black  stools  may  be  produced  by  the 
administration  of  iron,  bismuth,  or  manganese.  In 
haemorrhage  high  up  in  the  intestine  the  altered 
blood  makes  the  stools  dark,  tarry-looking,  and  very 
offensive.  The  blackness  due  to  blood  may  be  dis- 
tinguished from  that  produced  by  drugs  by  mixing 
part  of  the  stool  with  twice  its  volume  of  water  and 
allowing  it  to  stand  in  a  glass  jar.  If  blood  be 
present  the  water  becomes  reddish ;  under  other 
conditions  it  remains  dark  or  greenish. 

Pallor  of  the  stools  may  be  due  to  an  obstruction 
to  the  entrance  of  bile  into  the  intestine,  as  in  jaun- 
dice, or  to  extreme  dilution  of  the  stool,  as  in  cholera. 

The  odoiir  of  the  faeces  is  due  to  the  presence  of 
indol  and  skatol.  The  absence  of  bile  seems  to 
favour  putrefaction,  hence  the  stools  in  jaundice  are 
often   very   offensive.     Cholera   stools,    on  the  other 


Naked-Eye  Characters.  85 

hand,  contain  ^'ery  little  organic  matter,  and  are 
almost  free  from  odour.  In  fermentative  processes 
in  the  intestine  the  stools  may  have  a  sour  smell. 

The  form  and  consistence  of  the  stools  is  of 
importance.  In  obstinate  constipation  the  stools 
may  be  much  drier  and  harder  than  normal,  and 
e\en  friable.  In  all  forms  of  diarrhoea  they  are 
more  fluid  than  normal,  and  may  even  be  watery. 
Slimy  stools  are  due  to  the  presence  of  an  excess 
of  mucus. 

It  is  important  to  note  whether  the  stools  are 
formed  or  fluid.  If  formed,  any  abnormality  in  the 
shape  should  be  noted.  The  stools  of  constipation 
have  often  the  form  of  round  balls,  frequently  coated 
with  mucus.  In  obstruction  in  the  large  intestine 
the  stools  may  be  ribbon-like.  If  ascites  is  present, 
the  pressure  of  the  fluid  on  the  bowel  often  leads  to 
flattening  of  the  feeces.  The  presence  of  a  rectal 
polypus  may  produce  a  groove  or  furrow  along  the 
fsecal  mass. 

In  order  to  facilitate  the  detection  of  abnormal 
ingredients,  the  stool  should  be  placed  on  a  fine 
sieve,  and  a  large  quantity  of  water  added.  The 
whole  is  then  shaken  and  stirred  up  till  the  soluble 
parts  are  all  washed  away.  The  residue  is  then 
examined. 

Gall  stones  are  easily  recognised.  It  is  important 
to  note  whether  they  are  facetted  or  not,  for  if  they 
are,  then  the  stones  are  multiple.  Particles  of  un- 
digested food,  fruit  stones,  foreign  bodies,  concretions 
— e.g.  those  produced  by  magnesia — and  parasites 
should  all  be  looked  for. 

The  full  consideration  of  the  parasites  which  may 
be  found  in  the  stools  is  undertaken  later.  We 
would  only  mention  here  that  one  has  often  to  search 
stools  for  the  head  of  a  tapeworm.  The  best  method 
of  procedure  in  sugh  a  case  is  to  add  to  the  stool  a 


86  Examination  of  Fmces. 

considerable  quantity  of  water  containing  a  little 
carbolic  acid,  and  to  shake  the  mixture  gently  for  a 
few  moments.  It  is  then  allowed  to  stand  for  about 
ten  minutes.  The  parasite  sinks  to  the  bottom,  the 
supernatant  fluid  is  poured  off",  and  more  water  added 
till  the  residue  is  nearly  colourless.  The  parasite 
will  then  be  readily  found.  The  head  is  only  about 
as  large  as  that  of  a  large  pin,  and  the  neck  about  as 
thick  as  a  stout  thread. 

Special  terms  are  applied  in  clinical  medicine  to 
some  particular  varieties  of  stool. 

The  hilious  stool  is  well  illustrated  in  the  typical 
stool  of  typhoid  fever.  Its  characters  are  described 
in  the  term  of  "  pea  soup  "  stool,  usually  applied  to  it. 

Watery  stools  are  found  in  all  cases  of  colliquative 
diarrhoea,  and  after  the  administration  of  hydragogue 
cathartics.  To  the  watery  stools  of  cholera  the 
special  name  of  rice-water  stools  is  applied.  Such  a 
stool  is  colourless,  devoid  of  odour,  alkaline  in  reac- 
tion, and  contains  a  number  of  small  flocculi,  consist- 
ing of  shreds  of  epithelium  and  particles  of  mucus. 
The  name  is  applied  to  it  from  its  resemblance  to  the 
water  in  which  rice  has  been  boiled.  Purulent^  or 
pus-containing,  stools  are  found  in  severe  dysentery 
or  intestinal  ulceration,  or  in  cases  where  an  abscess 
has  found  its  way  into  the  intestine.  Slimy  stools 
are  due  to  the  presence  of  an  excess  of  mucus,  and 
point  to  an  affection  of  the  large  bowel.  The  mucus 
may  envelop  the  fa;cal  masses,  or  may  be  intimately 
mixed  with  them.  Bloody  stools  vary  in  appearance 
according  to  the  site  of  the  haemorrhage.  If  the 
latter  takes  place  high  up,  the  stools  look  like  tar,  as 
has  been  already  mentioned.  In  an  ordinary  intus- 
susception the  stools  may  look  like  red  currant  jelly, 
In  those  rare  cases  in  which  the  intussusception 
occurs  in  the  jejunum  the  appearance  of  the 
material  passed   per    anum    has    been    compared    to 


Microscopic  Characters.  87 

that  of  a  melted  strawberry  ice.  If  the  h?eiiiorrhage 
be  from  the  large  intestine,  the  blood  is  less  intimately 
mixed  with  the  fgecal  matter,  and  may  even  be  of  a 
bright  colour.  In  haemorrhage  from  the  rectum  or 
anus  it  may  merely  streak  the  fsecal  masses. 

2.  Microscopic  examination    of  faeces. 

If  the  stool  is  solid,  a  small  particle  of  it  should 
be  picked  up  with  forceps,  placed  on  a  slide,  and 
mixed  with  a  little  salt  solution.  If  the  stool  is 
liquid,  a  portion  of  the  deposit  should  be  removed 
with  a  pipette  and  placed  on  the  slide  without  salt 
solution.  A  cover  glass  is  put  on  in  either  case, 
and  the  specimen  examined  directly.  Should  it  be 
desirable  to  use  any  stain,  a  little  very  dilute  watery 
eosin  is  to  be  recommended  for  the  purpose. 

One  may  find  (1)  particles  of  food — as  already 
described  in  the  vomit;  (2)  cells — red  blood  cor- 
puscles, intestinal  epithelial  cells,  pus  corpuscles,  or 
leucocytes ;  (3)  crystals  ■ —  e.g.  triple  phosphates, 
phosphate  of  lime,  cholesterin,  fatty  and  hjematoidin 
crystals.  Xone  of  these  has  any  pathological  sig- 
nificance. (4)  Parasites  and  bacteria  may  also  be 
found.  The  latter  are  considered  in  Chapter  XI V.  ; 
the  former  demand  a  more  detailed  description  here. 
The  parasites  which  occur  in  the  intestinal  tract 
include  worms  and  protozoa.  The  worms  belong 
either  to  the  nematoda  or  to  the  flat  worms,  the  latter 
group  containing  the  cestoda,  which  are  fairly 
common,  and  the  flukes,  which,  in  Europe  at  least, 
are  by  no  means  ordinarily  found  in  man. 
(A)  Nematoda. 

1.  Perhaps  the  commonest  of  all  internal  parasites 
is  the  small  threadworm,  Oxyuris  vermiculariSf 
whose  presence  is  associated  with  considerable  itching 
about  the  anus.  It  inhabits  the  large  intestines,  caecum 
and  vermiform  appendix,  and  specimens  can  often  be 
seen  wriggling  about  in  the  recently-passed  motions  of 


Examination  of  Keces. 


their  host.  To  the  naked  eye  they  look  Hke  small 
white  threads,  from  a  half  to  one  centimetre  in  length. 
Under  the  microscope  the  female  maybe  distinguished 


Fig.  9.  —  Oxyuris 
vermicularis. 

1,  male;  2,  female. 
Nat.  size.  {After 
Payne.) 


large 


uterus 


by  the 
filled  with  ova,  and  the 
pointed  posterior  end, 
whence  its  name  is  de- 
rived (Figs.    9,    10,    15, 

A). 

2     A§cai'ij§     luin- 

brjcoides  has  a  general 
resemblance  to  an  earth- 
worm. It  measures,  as 
a  rule,  from  six  to  eight 
inches,  and  sometimes 
considerably  exceeds  this 
length.  Not      infre- 

quently its  presence  in 
children  is  associated 
with  nervous  disorders. 
The  ova,  which  can  oc- 
casionally be  found  in 
the  dejecta,  have  brown- 
ish yellow  granular  con- 
tents, and  in  many  cases 


mt 


Fig.  10.— Oxyuris  verniiculari.s. 

a,  young  female  ;  b,  male ;  c,  mature 
female.    Magnified.    {After  Payne.) 


Nematoda. 


89 


Fig. 


11.— Ankylostoma 
duodenale. 


the  shell  is  surrounded  by  an 
irregular  albuminous  sheath  (Fig. 
15,  B). 

3.  Ascaris  iiiy!i»tax,  a  closely- 
allied       worm,      is 
sometimes  parasitic 
in     children ;     the 
infection  is  got  from 


a,  male 

size. 


;  6,  female.    Nat. 
{.After  Payne.) 


cats. 

4.    Ankylost- 
oma duodenale 

is  a  parasite  whose  presence  is  fraught 
with  much  greater  risk  to  the  host  than 
that  of  those  already  mentioned,  as  it 
causes  profound  anaemia  by  drawing 
blood  from  the  wall  of  the  bowel.  It 
lives  for  the  most  part  in  the  upper  part 
of  the  jejunum,  and  its  existence  there 
is  rendered  probable,  when,  in  an 
infested  district,  severe  anaemia,  other- 
wise inexplicable,  sets  in.  The  diag- 
nosis is  clinched  by  the  discovery 
of  ova  in  the  motions.  They  exhibit 
a  segmented  yolk,  enclosed  in  a  thin 
shell,  and  are  sufficiently  numerous 
to  be  readily  detected.  The  adult 
worm,  which  is  rarely  seen  before 
therapeutic  agents  have  been  em- 
ployed, is  about  half  an  inch  long,  and 
the  mouth  is  provided  with  four  claw- 
like teeth.  The  male  is  distinouished 
by  its  lobed  caudal  bursa  (Figs.  11, 
12). 

5.  Triclioceplialus  dispar 
is,  perhaps^  a  commoner  parasite 
than  might  be  suspected  ;  its  presence 
does   not    seem   to    cause    any    very 


Fig.   12.  —  Ankylo- 
stoma duodenale. 

«,  female;  b,  male. 
Magnified,  c,  nat. 
size.    (,Bristowe.^ 


90  Examination  of  Fmces. 

serious  inconvenience.  The  length  of  the  worm  is 
under  two  inches,  its  colour  is  white,  the  anterior 
portion  is  much  narrower  than  the  posterior,  and 
is    buried   in   the  mucosa  of  the  csecum.       The  ova 

are  very  character- 
istic, and  when 
present,  are  readily 
recognised  (Figs. 
13,  15,  c). 

6.     Trichina 
spiralis  occurs  in 
Fig.  13.— Trichocephaiiis  dispar.  the     alimentary 

a,  female :  &,  male.    Nat.  size.    (^After  Payne.)  -i     •        ,  i 

canal,  m  the  sexu- 
ally mature  state.  The  striped  muscles  are  the 
habitat  of  the  embryonic  form,  and  when  much 
affected  they  may  become  shortened.  This  is  well 
seen  in  the  biceps,  where  the  contraction  induces  a 
very  typical  flexion  of  the  forearm.  'J.'he  adult  male 
measures  1*5  mm.  in  length;  the  female,  which  is 
viviparous,  is  about  twice  as  long. 

(B)  Cestoda. 

Many  different  kinds  of  tapeworm  have  been  found 
as  parasites  in  man,  but  those  of  most  importance 
are  Taenia  solium,  T.  mediocanellata,  and  T.  echin- 
ococcus.  Taenia  cucumerina  is  also  occasionally  found 
in  children.  Besides  its  occurrence  in  the  fully 
developed  state,  T.  solium  may  be  present  in  the 
tissues,  in  the  form  of  a  cysticercus  ;  T.  mediocanel- 
lata is  almost  never  found  in  this  condition  in  man  ; 
whilst  T.  echinococcus  always  occurs  in  the  cystic 
stage,  and  has  never  been  found  in  the  mature  con- 
dition in  the  human  intestinal  tract  (Fig.  14). 

The  presence  of  an  adult  tapeworm  in  the  bowel 
is  generally  revealed  by  the  passage  of  ripe  proglot- 
tides in  the  stools,  and  after  the  administration 
of  anthelmintics  the  head  may  be  detected  by  the 
methods  previously  described. 


Cestoda. 


91 


1.  Tsviiia  solium  (Figs.  14,  «,  a,  15,  d).     The 

mature  Avorm  measures  2  or  3  yards  in  length ;  a  ripe 
proglottis  is  about  10  mm.  long,  and  6  mm.  l3road,  with 


Fig.  14. — Cestoda. 

a.  head  of  TiBuia  solium,  x  10 ;  a',  mature  segment  of  do.,  nat.  size  :  h.  Lead  of 
T.  sagiuata,  x  10;  V,  mature  segment  of  do.,  nat.  size  ;  c,  head  of  Bothrio- 
cephaluslatus,  x  10;  c'.  mature  segments  of  do.,  nat.  size;  d,  head  of  T.  cucu- 
merina,  x  lo  ;  rf', mature  segment  of  do.,  nat.  size  ;  e,  T.  echinococcus,  x  10  ; 
e',  do,  nat.  size  ;  /,  hydatid  scolex  (invaginated),  x  250  ;  <j,  hydatid  booklets, 
x  2.50;  /i,  hydatid  membrane  (ectocyst),  x  250  ;  ?,  booklet  from  cysticercus, 
X  250. 

the  sexual  opening  placed  laterally ;  the  uterus  is 
coarsely  branched.  The  head,  whose  size  is  about  the 
same  as  the  head  of  a  large  ordinary  pin,  has  four 
suckers,  often  pigmented,  and  a  small  rostellum,  with  a 


92  Examination  of  Faeces. 

ring  of  20  to  30  booklets.  The  ova,  which  are  nearly 
spherical,  are  readily  recognised  by  their  thick  shell, 
with  radiating  striations.  Inside  the  ovum,  when 
mature,  the  six  booklets  of  the  embryo  may  be 
visible. 

The  cysticercus  varies  in  size  according  to  its 
situation,  but  never  attains  anything  approaching  the 
magnitude  of  an  echinococcus  cyst.  The  vesicle 
contains  one  head  only,  whence  the  adult  worm  is 
developed. 

2.  T.  mediocanellata^  (saginata)  is  larger 
than  T.  solium,  and  attains  a  length  of  5  to 
9  yards.  The  ripe  proglottides  measure  16  mm.  in 
length,  by  5  mm.  in  breadth,  but  immature  segments 
are  broader  than  they  are  long.  Yery  often  they 
exhibit  movements  after  they  have  been  detached 
from  the  strobilus  and  have  passed  from  the  bowel. 
The  sexual  opening  is  lateral,  and  the  uterus  is 
finely  ramified,  with  frequent  dichotomous  divisions 
of  the  primary  branches.  The  head  is  rather  square 
in  outline,  and  is  larger  than  that  of  T.  solium.  It 
has  four  suckers,  but  is  devoid  of  booklets.  The 
ova  closely  resemble  those  of  T.  solium,  but  arc 
slightly  longer  in  proportion  to  their  breadth  (Figs. 
14,  h,  b',  15,  e). 

3.  T.  ecliiaiococciis. — The  adult  worm,  which 
consists  of  a  head  and  three  segments,  and  whose 
length  is  only  four  or  five  millimetres,  need  not  be 
fully  described^  since  it  is  not  found  in  man.  The 
cystic  stage  is  very  important,  as  it  gives  rise  to 
serious  disease  in  many  of  the  viscera,  and  especially 
in  the  liver. "^  The  cysts  of  this  taenia  are  not  simple, 
but  produce,  from  their  inner  surface,  one  or  two 
generations  of  secondary  vesicles,  on  which  the  brood- 

*  The  so-called  "hydatid  thrill"  is  described  elsewhere  (p.  57). 
It  may  occur  where  there  are  no  daughter  cysts,  and  it  may  be 
absent  when  daughter  cysts  occur. 


Cestoda.  93 

capsules,  containing  tlie  cestode  heads  are  formed. 
During  the  period  in  which  this  process  is  going  on  the 
primary  vesicle  dilates  to  accommodate  its  increasing 
contents,  and  may  eventually  reach  the  size  of  a 
cocoa-nut.  The  vesicles  may  rupture  spontaneously 
and  their  contents  may  escape  by  the  lungs,  by  the 
bowel,  or  by  the  urinary  passages,  or  specimens  may 
be  obtained  by  aspiration,  or  after  surgical  interference. 
In  a  case  of  suspected  hydatid  disease  one  may  re- 
quire to  found  the  diagnosis,  either  on  the  chemical 
nature  of  the  fluid  withdrawn,  or  on  the  recognition 
of  booklets  or  scolices,  or  on  the  appearance  of  the 
ectocyst,  portions  of  which  are  sometimes  discharged, 
especially  when  the  cyst  has  opened  into  the  lungs 
and  bronchi  (Fig.  14,  e,  e',  yj  g,  h). 

The  Jiuid  is  clear,  alkaline,  devoid  of  albumen, 
and  contains  abundance  of  sodium  chloride  and 
traces  of  glucose.  Its  density  is  low,  being  gene- 
rally under  1-010.  The  appearance  of  echinococcus 
hooklets  is  shown  in  Fig.  1-1,  g,  i.  The  scolex,  if 
it  is  obtained  in  a  perfect  condition,  is  about  1  to 
li  mm.  in  diameter,  and  a  number  of  them  often 
spring  in  a  group  from  one  brood-capsule.  They 
have  four  suckers  and  a  crown  of  hooklets. 
Portions  of  the  ectocyst  appear  as  whitish-yellow 
shreds,  which  can  be  recognised  under  the  microscope 
( X  250  diam.)  by  their  lamination,  and  by  the 
pectinate  markings  on  the  laminae  (Fig.  14,  h). 

4.  T.  cuctimeriiia  and  Botliriocephaliis 
latiiSf  though  rare  in  Britain,  are  common  in  some 
parts  of  Europe.  The  appearance  of  the  head,  and 
a  mature  segment  of  each  is  shown  in  Fig.  14,  d,  d', 
c,  c',  and  Fig.  15,  F. 

(C)  Trematoda  (Fig.  15). 

1.  Distonia  hepatieuni  (Fig.  15,  g)  is  rather 
rare  as  a  human  parasite.  When  it  does  occur,  the 
ova  may  be  found  in  the  fseces,  and  are  recognised  by 


94 


Examination  of  Faeces. 


Fig.  15.— Ova  of  Entozoa,  x  350.    {After  Heller.) 

A    oxyuris  verniicularis ;  b,  ascaris   Uinibriooides  ;  c,  tricliocephalus  dispar  ; 
'       D  tSBnia  solium  ;  e,  taenia  luediocanellata;   p,  bothriocephalus  latiis ;  G, 
distonia  hepaticum  ;  H,  distonia  lanceolatum. 


Protozoa. 


95 


their  brown  colour,  and  by  the  presence  of  an  oper- 
culum at  one  pole.  The  adult  fluke  is  leaf- shaped, 
and  measures  about  25  mm.  by  12  mm. 

2.  Distoiiia  laiiccolatuiii  (Fig.  15,  h)  is  con- 
siderably smaller,  and  is  narrower  in  proportion  to 
its  length.  The  ova  are  similar  to  those  of  D.  hepa- 
ticum  but  smaller. 

Protozoa. 

A  number  of  protozoa,  including  members  both  of 

the  Rhizopoda  and  Infusoria,  have  been  found  in  the 

fseces.     The  only  one  which  is  of  undoubted  clinical 

importance  is  the  Amoeba    dyseiiterise,  which  is 


Fig.  16. — AmfEbic  dysentery. 

a,  amoeba  dysenteriae  fixed  and  stained  {Councilman) ;  b.  aniceba  dysenterias  in 
stools  {after  Losch,  Virchow's  "  Archiv.,"  Bd.  65). 

present  in  a  great  proportion  of  cases  of  tropical 
dysentery,  and  also  in  tropical  abscess  of  the  liver 
(Fig.  16). 

When  in  a  state  of  activity  they  vary  in  form, 


96  Examination  of  F.-eces. 

and  throw  out  pseudopodia ;  at  rest  they  hecome 
spherical,  measure  on  an  average  from  12  to  26/x 
in  diameter,  and  generally  exhibit  a  nucleus.  The 
resting  condition  is  that  in  which  they  are  usually 
found  in  the  faeces,  when  they  are  recognised  by  their 
high  refractility  and  their  greenish  tint.  For  careful 
examination,  Lafleur*  recommends  that  a  portion 
of  the  dejecta  should  be  hardened  in  Miiller's  fluid, 
and  subsequently  cut  and  stained  like  sections  of 
tissues ;  or  cover  glasses,  smeared  with  a  thin  film 
of  the  f?ecal  material,  can  be  prepared.  The  stain 
which  he  prefers  is  methylen  blue.  The  amceba 
is  most  easily  detected  in  the  little  masses  of  mucus 
which  occur  in  the  stool,  and  attention  should  always 
be  carefully  directed  to  these. 

*  AUbutt's  ".System  of  Medicine,"  vol.  ii.,  ^.  755. 


97 


CHAPTER    IV. 

Circulatory    SystExM, 

SECTION  I. -ANATOMY. 

This  system  is  composed  of  two  main  elements — 
the  heart  and  the  bloodvessels — and  these  are  for 
the  most  part  dealt  with  separately,  although,  when 
the  chest  is  exposed  for  the  examination  of  the 
heart,  the  vessels  in  the  thorax  and  at  the  root  of 
the  neck  are  more  conveniently  examined  along 
with  it.      {See  Plate  I.) 

Tlie  heart  lies  obhquely  in  the  thorax,  being  in- 
clined from  above  downwards,  forwards,  and  to  the 
left.  Two-thirds  of  it  lie  to  the  left  of  the  middle 
line.  The  part  which  reaches  highest  in  the  thorax 
is  the  left  auricular  appendix.,  which  in  the  cadaver 
extends  as  far  np  as  the  second  left  costal  cartilage. 
During  life  it  is  usually  opposite  the  second  inter- 
space or  lower  border  of  the  second  cartilage,  as 
the  diaphragm  then  occupies  a  lower  level.  The 
greater  portion,  however,  of  the  left  auricle  lies 
posteriorly,  and  constitutes  the  hindmost  cavity  of 
the  heart. 

The  right  auricle  is  the  chamber  that  lies  most 
to  the  right.  It  extends  somewhat  beyond  the 
right  margin  of  the  sternum,  and  its  border  may 
be  traced  by  a  curved  line  joining  the  third  and 
seventh  right  chondro-sternal  articulations,  and 
reaching  about  one  inch"^  to  the  right  of  the 
sternum. 

The  right  ventricle  occupies  the  great  portion 
of    the   front    of   the   heart.      Its    inferior    margin 

*  Luschka. 
II 


98  Circulatory  System. 

extends  from  the  seventh  right  chondro  sternal  arti- 
culation to  the  apex,  and  constitutes  the  lower 
border  of  the  heart. 

The  left  ventricle  only  appears  in  front  as  a 
narrow  strip,  scarcely  half  an  inch  broad,  and  its 
outline  completes  that  of  the  heart  on  the  left, 
where  its  border  forms  a  curved  line,  ascending 
from  the  apex  to  the  lower  margin  of  the  second 
left  interspace  at  a  point  just  internal  to  the  para- 
sternal line. 

The  topographical  anatomy  of  the  valves  of  the 
heart  and  of  the  great  vessels  will  be  discussed  in 
connection  with  auscultation,  as  it  is  in  this  de- 
partment that  a  knowledge  of  their  situation  is  most 
necessary  (pp.  132-157). 

The  most  important  organs  which  come  into 
relation  with  the  heart  are  the  lungs  on  either 
side,  the  liver  below,  and  the  great  vessels  above. 
A  small  portion  of  the  anterior  surface  is  only 
separated  from  the  thoracic  wall  by  the  anterior 
mediastinum,  whilst  behind,  the  heart  is  in  relation 
with  the  structures  that  occupy  the  posterior 
mediastinum. 

That  portion  of  the  anterior  aspect  of  the  chest 
which  overlies  the  heart  is  known  as  the  prsecordial 
region. 

It  is  often  necessary  to  deifine  the  exact  situa- 
tion of  a  point  on  the  front  of  the  thorax,  and 
certain  landmarks,  some  natural  and  some  artificial, 
are  commonly  made  use  of  for  this  purpose. 

Tlie  ribs  and  interspaces  on  either  side  form 
convenient  horizontal  landmarks.  In  order  to  count 
them,  one  must  feel  for  the  ridge  which  marks  the 
junction  of  the  manubrium  with  the  body  of  the 
sternum,  known  as  the  angle  of  Louis.*  When 
this  has  been  found,  by  running  the  finger  outwards 
*  Angulus  Ludovici. 


Ana  TOM V.  99 

it  reaches  the  second  costal  cartilage,  which  articulates 
with  the  sternum  at  this  level.  It  is  then  easy  to 
reckon  upw^ards  or  downwards  to  the  other  ribs.  The 
detenuination  of  the  first  rib  directly  is  neither  so  easy 
nor  so  certain,  since  it  is  overlapped  by  the  clavicle. 

In  order  to  define  the  distance  of  any  given  point 
from  the  mesial  sagittal  plane  of  the  body,  a  series 
of  vertical  lines  are  imaojined  to  be  drawn  on  the 
chest.  These  are  the  midsteriial  and  lateral 
sternal  lines,  drawn  down  the  middle  and  either 
border  of  the  sternum ;  the  mammary  line,  best 
defined,  since  the  situation  of  the  nipple  is  inconstant, 
as  the  vertical  line  dropped  from  the  centre  of  the 
clavicle,  or,  what  amounts  to  the  same  thing,  the  line 
midway  between  the  middle  of  the  suprasternal  notch 
and  the  tip  of  the  acromion ;  the  parasternal  line 
midway  between  the  lateral  sternal  and  mammary 
lines;  the  anterior,  mid,  and  posterior  axillary 
lines  descending  from  the  anterior  border,  the  centre, 
and  the  posterior  border  respectively,  of  the  axilla  ; 
and  the  scapular  line,  which  is  defined  as  the 
vertical  line  drawn  through  the  angle  of  the  scapula. 

The  methods  commonly  employed  in  the  examina- 
tion of  the  heart  are  inspection,  palpation,  percussion, 
and  auscultation.  These  will  be  taken  up  consecu- 
tively, although  in  practice  inspection  and  palpation 
are  often  advantageously  combined. 

SECTION   II.— INSPECTION. 

For  inspection  of  the  chest,  the  patient  should  be 
stripped  to  the  Avaist,  and  set  in  a  good  light,  either 
sitting  up  or  lying  on  his  back.  The  observer  should 
directly  face  him,  but  must  be  careful  not  to  obstruct 
the  light.  In  some  cases  the  observer  may  with 
advantage  take  up  a  position  at  the  top  of  the  bed, 
and  lower, his  head   until  he  looks  along  the  chest 


loo  Circulatory  System. 

tangentially.     By  this  manoeuvre  he  will  be  able  to 
study  various  j)ulsations  with  great  facility. 

The  following  points  must  then  be  systematically 
noted  : — 

(1)  The  shape  of  the  prsecordia  ; 

(2)  Pulsations  in  the  pragcordial  region; 

(3)  Bulging  or  pulsation  outside  the  prsecordia, 
either  at  the  root  of  the  neck,  or  the  front  of  the  chest, 
or  the  epigastrium  (scrobiculus  cordis)  ; 

(4)  The  presence  or  absence  of  distended  veins  on 
the  chest  wall  or  in  the  neck. 

1.   The  shape  of  the  prsecordia. 

In  health  the  chest  is  bilaterally  symmetrical,  and 
there  is  no  greater  prominence  on  the  left  side  than 
on  the  corresponding  area  of  the  right.  When  the 
right  pectoral  muscles  are  exceptionally  well  developed, 
the  prsecordia  may  be  less  prominent  than  the  right 
side  of  the  chest. 

In  cases  where  the  praecordial  area  is  pro- 
minent, it  must  be  remembered  that  other  conditions 
than  disease  of  the  heart  may  have  caused  the  projection, 
whilst  it  is  equally  to  be  observed  that  serious  disease 
of  the  heart  is  comparatively  seldom  accompanied 
by  bulging  of  the  prsecordia  unless  it  had  already 
manifested  itself  when  the  patient  was  young  and 
the  bones  were  incompletely  ossified. 

Should  prominence  be  observed,  note  whether  the 
ribs  are  involved,  or  whether  the  intercostal  spaces 
alone  bulge.  The  latter  condition  occurs  in  pericarditis 
with  effusion.  Prominence  of  the  prsecordia  may  be 
due  to  disease  in  the  framework  of  the  thorax,  such  as 
scoliosis,  parietal  tumour,  or  abscess,  or  to  a  diseased 
condition  of  the  thoracic  contents,  such  as  cancer  of 
the  lung  or  effusion  into  the  pleural  cavity,  medi- 
astinal tumour,  fluid  in  the  pericardium,  enlargement 
of  the  heart,  especially  if  it  occur  in  early  life,  and 
aneurysm  behind  or  above  the  heart. 


Inspection.  ioi 

Flattening^  of  the  prsecorclia  may  be  con- 
genital ;  it  may  mark  the  former  occurrence  of  peri- 
carditis ;  it  may  be  due  to  retraction  of  the  lung ;  and 
in  some  instances,  particularly  in  certain  trades,  it 
may  be  the  result  of  pressure. 

2.  Pulsations    in   the  prceeorclial    region. 

Besides  the  movement  of  respiration,  which  affects 
the  praecordia  with  the  rest  of  the  chest,  an  impulse 
which  occurs  three  or  four  times  to  each  respiration 
is  generally  seen  in  the  lowest  and  leftmost  part  of 
that  region. 

This  pulsation  is  called  the  apex  beat  of  the 
heart,  and  in  health  usually  exhibits  the  following 
characters  : — 

Firstly. — It  is  found  in  the  fifth  left  intercostal 
space. 

Secondly. — It  is  limited  to  an  area  less  than  an 
inch  in  breadth,  and  is  only  visible  in  one  inter- 
space. 

Thirdly. — It  is  situated  outside  the  left  parasternal 
line,  and  inside  the  left  mammary  line  ;  and 

Fourthly. — It  is  due  to  the  impact  on  the  chest 
wall  of  the  apical  segment  of  the  heart,  and  for 
clinical  purposes  the  actual  apex  of  the  heart  may  be 
assumed  to  be  situated  at  the  lowest  and  leftmost 
part  of  the  above  area  of  pulsation,  although  it  may 
really  be  slightly  lower  down  and  farther  out,  under 
cover  of  a  rib. 

The  apex  beat  may  be  abnormal  in  force,  in 
position,  or  in  extent.  Even  in  perfect  health  if 
the  chest  is  well  clothed,  and  the  apex  lies  behind  a 
rib,  it  maybe  quite  invisible.  Disap2oearanGe,  therefore, 
of  the  apex  beat  is  not  to  be  regarded  as  necessarily 
indicative  of  disease,  though  it  must  not  be  forgotten 
that  it  is  in  cases  of  weak  action  of  the  heart  that  it 
is  most  frequently  absent  or  diminished  in  force. 
When  abolished,  its  place  may  be  taken  by  a  more 


I02  Circulatory  System. 

diffuse  impulse  over  the  lower  part  of  the  prsecordial 
area,  in  cases  where  the  apex  is  pushed  away  from 
the  chest  wall  by  a  dilated  right  ventricle,  or  when 
pericardial  effusion  separates  the  heart  from  the  front 
of  the  thorax.  On  the  other  hand,  the  apex  beat 
may  appear  to  be  more  forcible  than,  usual  in  cases 
where  the  heart's  action  is  excited,  where  the  chest 
wall  is  thin,  or  where  the  left  ventricle  is  hypertro- 
phied.  Such  changes  are  more  accurately  observed 
by  palpation,  and  will  be  discussed  under  that 
head. 

The  position  of  the  apex  beat  may  be  altered 
in  three  classes  of  cases.  The  cause  may  be  [a) 
congenital  where  the  heart  is  reversed  so  that  the 
apex  lies  to  the  right  (situs  viscerum  inversus),  or 
where  other  developmental  anomalies  are  present.  The 
displacement  of  the  apex  beat  may  be  due  to  (h) 
extrinsic  causes  where  the  heart  is  displaced  by 
diseased  conditions  of  surrounding  viscera  which  push 
or  pull  it  from  its  usual  site.  Instances  of  this  are 
found  in  pleurisy  with  effusion,  in  abdominal  tumours, 
and  in  retraction  of  a  lung. 

Where  the  heart  is  pushed  over  to  the  right  by  a 
left  pneumothorax,  or  pleuritic  effusion,  the  pul- 
sation which  is  conspicuous  to  the  righthand  side  of 
the  sternum  is  not  that  of  the  apex,  which  is  usually 
lying  somewhere  behind  the  bone,  but  is  due  to 
pulsation  of  the  right  ventricle  and  auricle. 

Thirdly,  the  displacement  may  result  from  (c) 
disease  of  the  heart  or  pericardium.  The  apex  beat 
is  displaced  mostly  outwards  when  the  heart  is 
dilated ;  downivards  and  outwards  when  the  left 
ventricle  is  hypertrophied ;  and  often  upwards  when 
fluid  is  present  in  the  pericardial  sac. 

In  addition  to  these  causes,  it  should  be  remem- 
bered that  the  position  of  the  apex  beat  varies  con- 
siderably   with  the    patient's  age  :    in  children  it   is 


Inspection. 


lo- 


usually  as  high  as  the  fourth  interspace"^   (Fig.  17)  ; 
in  the  aged  it  descends  as  low  as  the  sixth. 

In  certain  cases  the  apex  beat  is  rej)laced  by  an 
indrawing  of  the  same  area  during  cardiac  systole. 
This,  when  it  is  marked  in  degree^  and  when  it 
appears  over  an  extensive  area  of  the  lower  segment 


Fig.  17. — The  heart  in  an  infant.     {After  Symington.) 


of  the  preecordia,  indicates  pericardial  adhesion. 
When  only  slightly  visible  and  limited  to  the  apex, 
it  is  of  no  great  consequence. 

The  extent  of  the  apex  beat  is  increased  in 
cases  where  the  heart  is  hypertrophied.  This  con- 
dition  must  not  be  confused  with   diffuse  pulsation 

*  Even  in  young  children,  although  the  apex  beat  is  seen  in 
the  fourth  interspace,  the  actual  apex  lies  lower  down — usually 
behind  the  fifth  rib. 


I04  Circulatory  System. 

over  the  prsecordia.  Doubling  of  the  apex  beat  some- 
times occurs,  and  may  be  due  to  various  causes,  of 
which  the  most  important  are  alternate  systole  of 
the  right  and  left  heart,  and  hemi-systole. 

The  consideration  of  other  pulsations  which 
may  be  visible  in  the  prsecordial  region  must  next  be 
undertaken.  Allusion  has  already  been  made  to  the 
diffuse  pulsation  which  occurs  when  the  right  ventricle 
is  dilated  and  hypertrojDhied,  and  which  in  these 
circumstances  is  visible  over  the  lower  part  of  the 
area  in  several  of  the  intercostal  spaces,  and  nearer 
the  middle  line  than  the  normal  apex  beat. 

Pulsation  is  also  seen  at  times  in  the  second  left 
intercostal  space.  It  may  arise  either  in  the  pul- 
monary artery,  which  lies  half  under  cover  of  the 
left  side  of  the  sternum,  and  half  under  the  inner 
end  of  this  inters])ace,  or  in  the  left  auricular 
appendix.  In  the  former  case,  it  follows  the  apex 
beat,  and  marks  the  closure  of  the  pulmonary  valves ; 
in  the  latter  case,  Avhich  is  not  common,  it  imme- 
diately precedes  the  apex  beat. 

In  chests  which  have  thin  parietes,  and  especially 
when,  in  addition,  the  left  lung  is  retracted  from 
phthisis  or  other  disease,  pulsation  of  a  diflPuse  nature 
can  be  observed  over  most  of  the  interspaces  of  the 
prsecordial  region,  as  well  as  at  the  apex.  In  these 
cases  the  apex  beat  still  causes  a  limited  area  of 
the  chest  wall  between  the  left  parasternal  and 
mammary  lines  to  bulge  forward  with  each  beat 
of  the  heart,  whilst  the  diffuse  pulsation  which  is 
caused  by  the  systole  of  the  right  ventricle  is 
associated  with  indrawing  of  some  portion  of  the 
intercostal  spaces.  This  retraction,  accompanied  by 
a  normal  apex  beat,  and  not  confined  to  the  lower 
prsecordial  segment,  must  not  be  confused  with  the 
systolic  indrawing  already  described  as  characteristic 
of  pericardial  adhesion. 


Inspection.  105 

3.  Pulsations  outside  the  praccordia. 

In  addition  to  the  pulsations  already  described, 
movements  should  be  looked  for  at  the  root  of  the 
neck,  the  front  of  the  chest,  and  the  epigastrium. 

At  the  root  of  the  neck,  pulsation  may 
occur  either  in  the  episternal  notch  or  external  to  the 
sternomastoid. 

In  the  episternal  notch,  the  pulsation  is 
usually  systolic  in  time,  and  when  well  marked  is 
generally  an  indication  of  dilatation  or  aneurysm  of 
the  transverse  portion  of  the  arch  of  the  aorta.  Less 
commonly  it  is  due  to  a  thyroidea  ima  artery  of  con- 
siderable size,  or  to  an  abnormal  origin  of  the 
right  subclavian  from  a  point  to  the  left  of  the 
middle  line.  Palpation  generally  enables  these  con- 
ditions to  be  discriminated.  Pulsation  here  and 
in  the  carotids  is  not  uncommonly  seen  in  cases 
of  chlorosis  and  in  other  forms  of  anaemia. 

Ontside  the  sternomastoid  various  pulsa- 
tions may  be  observed.  These  may  be  either  arterial 
or  venous.  The  carotids  pulsate  "sdsibly  on  exertion ; 
from  mental  excitement  ;  in  diseases  which  cause 
excitement  of  the  circulatory  system,  such  as 
exophthalmic  goitre ;  in  cases  of  hypertrophy  of  the 
left  ventricle,  especially  when  associated  with  aortic 
incompetence ;  and  in  aneurysm  of  the  artery. 

The  jugular  veins  may  exhibit  undulation  or 
pulsation.  This  is  usually  caused  by  back  pressure 
of  blood  on  the  right  side  of  the  heart.  It  Avill 
be  discussed  under  the  venous  pulse  (p.  175). 

In  the  thorax,  besides  the  pulsations  referred 
to  as  occurring  in  the  prsecordial  region,  a  diastolic 
jmlsation  may  occasionally  be  observed  in  the 
second  right  intercostal  space,  and  results  from  the 
closure  of  the  aortic  valves.  An  im23ortant  source 
of  pulsation  in  unusual  parts  of  the  thorax  is 
aneurysTTi  of  the  aorta.     Such  aneurysmal  pulsations 


io6  Circulatory  System. 

always  manifest  themselves  at  first  above  the  level 
of  the  fourth  rib,  though  at  a  later  period  they 
may  affect  a  very  considerable  portion  of  the  chest 
wall.  The  position  of  the  impulse  varies  accord- 
ing to  the  part  of  the  aorta  which  is  diseased.  If 
the  ascending  aorta  is  affected,  the  pulsation  is 
chiefly  to  the  right  of  the  sternum,  whilst  the  trans- 
verse aorta  gives  rise  to  pulsation  under  the  manu- 
brium sterni,  and  the  descending  aorta  still  more 
to  the  left.  Aneurysm  of  the  innominate  may 
project  far  into  the  neck.  The  time  of  this  pulsa- 
tion is  systolic,  following  immediately  on  the  apex 
beat,  and  it  may  be  observed  to  be  expansile  in 
character.  The  pulsation  will,  of  course,  be  much 
earlier  manifest  when  the  vessel  lies  behind  soft 
parts  than  when  it  is  covered  by  bone. 

Pulsating  empyetna  may  be  present ;  it  generally 
occupies  the  prsecordial  area  from  which  the  heart 
is  more  or  less  displaced,  and  malignant  tumours  with 
a  large  blood  supply  may  also  give  rise  to  pulsation  in 
the  part  of  the  chest  wall  that  overlies  them. 

Ill  the  epig^astrium  there  may  be  several 
kinds  of  pulsation.  The  first  thing  to  be  deter- 
mined is  whether  it  is  strictly  systolic,  coinciding 
exactly  with  the  apex  beat,  or  whether  the  pulsation 
is  slightly  delayed,  so  as  to  appear  just  after  the 
apex  beat  has  occurred. 

In  the  former  case  the  pulsation  is  caused  by 
a  dilated  and  hypertrophied  right  ventricle,  which 
either  conveys  its  impact  directly  to  the  parietes, 
or  does  so  indirectly  by  exercising  a  thrust  upon 
the  liver,  or  else  it  is  due  to  the  apex  beat 
of  a  heart  displaced  to  the  right  by  some  diseased 
condition,  of  which  the  most  important  are  left-sided 
pleurisy  and  pneumothorax. 

In  the  case  of  delayed  pulsation  the  cause  may 
be  arterial.     The  existence   of  an  aneurysm  of  the 


Ins  PEC  TiON.  107 

abdominal  aorta  would  produce  such  an  effect.  More 
commonly,  however,  the  condition  is  simply  neurotic ; 
whilst,  in  other  instances,  the  pulsation  of  a  normal 
abdominal  aorta  is  conveyed  to  the  surface  either  by 
the  liver  or  by  an  abdominal  tumour,  such  as  pyloric 
cancer,  which  lies  in  front  of  it.      {See  also  p.  52.) 

In  cases  of  regurgitation  from  the  right  heart 
pulsation  also  occurs  just  after  the  apex  beat,  and  is 
due  to  a  distensile  pulsation  of  the  liver  itself  from 
the  back  flow  of  blood  into  the  hepatic  veins. 

It  is  comparatively  rare  to  observe  a  systolic  de- 
2)7'ession  of  the  eingastrium.  If  well  marked,  it  would 
probably  indicate  adhesions  resulting  from  an  old 
pericarditis. 

In  order  to  observe  with  greater  facility  the 
characters  and  time-relations  of  these  various  pulsa- 
tions, one  can  employ  small  flags,  made  as  light  as 
possible  and  attached  to  the  various  areas  of  the  chest 
wall.  To  determine  whether  a  pulsation  is  expansile, 
place  one  of  these  flags  on  either  side  of  the  tumour. 
If  it  be  expansile  their  free  extremities  will  recede 
from  each  other  as  the  tumour  fills.  If  it  is  desired 
to  time  the  occurrence  of  two  pulsations,  after  fixing 
a  flag  on  the  point  where  each  occurs,  one  may  take 
up  a  position  in  which  they  are  as  nearly  in  line  as 
possible.  It  is  then  quite  easy  to  determine  which  of 
them  begins  to  move  first. 

Flags  can  readily  be  improvised  by  taking  a  piece 
of  straw  or  a  bristle  about  three  inches  long,  fixing  a 
fragment  of  gummed  paper  to  one  end  and  surround- 
ing the  other  with  a  pellet  of  modeller's  wax  or  stiff' 
ointment  which  will  adhere  with  suificient  tenacity  to 
the  skin.  Other  more  primitive  methods  may  also  be 
used,  such  as  passing  a  pin  through  a  piece  of  adhesive 
plaster,  with  the  head  to  the  sticky  side,  and  fixing  it 
on  the  chest,  or  aflS.xing  little  cones  of  cotton  wool  to 
the  points  in  question  by  means  of  vaseline. 


io8  Circulatory  System. 

4.  Conspicuous  veins. 

The  veins  of  the  thoracic  wall  may  be  unduly 
conspicuous.  This  occurs  {a)  when  the  patient's  skin 
is  unusually  transparent ;  (6)  when  the  patient  has 
been  undergoing  considerable  exertion,  especially  when 
the  effort  is  of  such  a  kind  {e.g.  playing  a  wind 
instrument)  as  to  throw  a  strain  on  the  respiratory 
system ;  (c)  when  intrathoracic  tumours  impede  the 
return  of  blood  to  the  heart ;  (c?)  when  the  action  of 
the  right  side  of  the  heart  is  laboured  ;  (e)  when,  in 
consequence  of  portal  obstruction  or  of  blockage  of 
the  inferior  caval  system,  the  blood  returning  from 
the  abdominal  viscera  or  lower  limbs  is  forced  to  find 
its  way  through  collateral  chaijnels. 

In  a  number  of  instances,  where  the  right  side  of 
the  heart  is  slightly  overworked,  a  belt  of  dilated 
capillaries  appears  along  the  "line  of  attachment  of  the 
diaphragm. 

SECTION  IIL— PALPATION. 

By  palpation  the  observer  not  only  confirms  the 
facts  determined  by  inspection  and  adds  to  their 
precision,  but  is  also  able  to  detect  movements  and 
vibrations  which  are  too  slight  to  be  noted  by  the 
eye  alone.  For  palpation  the  patient  should  be 
placed  in  an  attitude  which  he  finds  easy  to  main- 
tain, since  the  exertion  which  a  constrained  posi- 
tion demands  is  certain  to  increase  the  observer's 
difficulties.  If  the  patient  is  lying  down,  care  must 
be  taken  to  keep  him  on  his  back.  By  turning  to  his 
left  side  he  will  produce  a  very  material  alteration  in 
the  position  of  the  apex  beat,  which  is  thereby  dis- 
placed outwards  towards  the  axilla  ;  whilst  if  he  lie  on 
his  right  side  the  apex  of  the  heart  may  recede  from 
the  chest  wall,  and  an  impulse,  which  in  the  more 
favourable  dorsal  attitude  would  be  easily  felt,  may 
entirely  disappear. 


Palpation.  109 

The  position  of  the  observer  is  almost  as  important 
as  that  of  the  patient.  For  the  examination  of  tlie 
prfBcordia  he  shoukl  stand  or  sit  at  the  top  of  the  bed, 
on  the  righthand  side.  He  should  then  place  his 
right  hand,  which  must  be  thoroughly  warm,  on  the 
patient's  chest,  so  that  the  palm  lies  over  the 
base  of  the  heart,  whilst  the  fingers  are  directed 
towards  its  apex.  To  begin  with,  the  whole  palm  of 
the  hand  should  be  in  contact  with  the  chest  wall, 
and  care  must  be  taken  not  to  dig  the  finger  tips  into 
the  intercostal  spaces,  as  this  causes  discomfort,  and 
may  thereby  interfere  with  the  subsequent  observa- 
tions. 

When  pulsation  is  detected  over  any  part  of  the 
region  under  examination,  its  exact  localisation  is  best 
determined  by  the  pulp  of  the  fingers. 

The  first  pulsation  to  attract  attention  is  that  due 
to  the  apex  beat.  Not  infrequently  the  fingers 
will  determine  that  this  is  really  farther  from  the 
middle  line  than  inspection  would  have  led  one  to 
suppose.  In  such  a  case  that  point  is  to  be  taken  as 
the  cardiac  apex,  which  is  the  leftmost  and  lowest 
where  the  finger  is  distinctly  forced  up  with  each  beat 
of  the  heart.  The  sensation  of  a  thrust  from  below 
raising  the  finger  is  important,  because  in  not  a  few 
cases  where  the  heart  is  acting  forcibly  it  communi- 
cates some  vibration  to  portions  of  the  chest  wall 
considerably  beyond  those  which  actually  lie  above  it. 

The  observer,  having  thus  determined  the  site  of 
the  apex  beat,  must  study  its  extent  and  character. 
As  has  been  previously  stated  (p.  101)  it  lies  in  health 
well  outside  the  left  parasternal  line,  but  never  be- 
yond the  left  mammary  line,  is  as  a  rule  confined  to 
one  interspace,  and  seldom  can  be  seen  over  an  area 
of  more  than  one  inch  in  diameter.  These  points 
will  now  be  carefully  examined  by  palpation,  and  any 
deviation  from  them  noted.     In  addition,  however,  an 


no  Circulatory  System. 

estimate  must  be  made  of  the  energy  with  which  the 
heart  is  acting,  and  the  apex  beat  may  be  found  to 
differ  from  the  normal — which  can  only  be  recognised 
by  continued  practice  at  the  bedside — in  possessing  a 
^'heaving''  character  in  cases  where  the  left  ventricle  is 
hypertrophied,  a  sha^y  slapping  impact  where  there  is 
irritability  of  the  heart,  or,  on  the  other  hand,  a 
feeble  or  almost  imperceptible  tap  when  the  heart  is 
fatty,  or  exhausted  towards  the  end  of  an  acute  fever. 

When  the  pulsation  of  the  apex  of  the  heart  is  so 
feeble  as  to  be  imperceptible  when  the  patient  is  lying 
down,  it  often  becomes  quite  distinct  if  he  sits  up,  and 
still  more  if  he  leans  forward.  If,  however,  these  pos- 
tures are  uncomfortable  for  a  patient  who  is  seriously 
ill,  it  is  better  to  forego  such  advantages  as  they 
afford  than  to  fatigue  one  whose  strength  is  already 
taxed  to  the  utmost.  The  chief  causes  of  im- 
palpable apex  beat  are  {a)  a  thick  chest  wall,  (6) 
a  feeble  heart,  and  (c)  emphysema  of  the  lungs. 

When  analysed,  the  varying  characters  of  the  beat 
will  be  found,  after  due  allowance  has  been  made  for 
the  thickness  of  the  chest  wall  and  intervening  lung, 
to  depend  upon  the  force  with  which  the  palpating 
finger  is  driven  upwards,  and  upon  the  celerity  and 
amplitude  of  the  movement  of  the  cardiac  apex  as  it 
approaches  the  front  of  the  thorax  at  each  ventricular 
systole.  A  shock  or  ''''jog  "  is  sometimes  felt  at  the 
apex  in  consequence  of  sharp  closure  of  the  pulmonary 
and  aortic  cusps. 

In  addition  to  pulsation,  vibrations  may  some- 
times be  observed  at  or  near  the  cardiac  apex.  Such 
vibrations  are  termed  thrills. 

The  time  of  their  occurrence  in  relation  to  the 
apex  beat  must  be  determined.  When  they  com- 
mence with  the  apex  beat  and  continue  during  the 
period  of  ventricular  contraction,  they  are  termed 
systolic ;  if  they  are  felt  whilst  the  ventricles  are 


Palpation.  hi 

relaxed,  they  are  termed  disistolic ;  if  they  occur 
near  the  close  of  diastole,  when  though  the  ventricles 
are  still  relaxed  the  auricles  have  entered  upon 
s3^stole,  and  run  up  to  the  apex  beat,  they  are 
termed  presystolic. 

These  thrills  may  be  due  either  to  valvular  disease, 
to  pericardial  friction,  or  to  friction  resulting  from 
pleurisy  over  that  part  of  the  left  lung  which  lies  in 
front  of  the  heart.  The  thrills  due  to  valvular  disease 
will  exhibit  a  more  definite  relation  to  the  apex- beat, 
both  in  point  of  time  and  situation  of  maximum  inten- 
sity, than  those  whose  origin  is  exocardial.  A  sys- 
tolic thrill,  best  felt  at  the  apex,  may  indicate  mitral 
regurgitation,  though  in  some  cases  the  thrill  of  aortic 
obstruction  is  very  distinctly  felt  in  this  area.  A 
diastolic,  and  still  more  a  presystolic  thrill,  when  it 
is  best  felt  at  or  just  internal  to  the  apex  beat,  is 
so  characteristic  of  mitral  obstruction  that,  if  it  is 
clearly  present,  one  may  with  a  high  degree  of 
probability  assume  that  lesion  to  exist,  even  in  the 
absence  of  all  other  signs  and  symptoms. 

Pericardial  or  pleural  tlirills  will  be  readily 
recognised  as  such  when  the  patient  is  auscultated 
{see  p.  156).  They  are  generally  to  and  fro  in 
character,  and  are  alwaj^s  audible  as  well  as  palpable"^. 
Pulsation  and  thrill  may  be  detected  over  the  right 
side  of  the  heart  when  its  chambers  are  dilated  and 
hypertrophied,  or  when  its  valves  are  diseased. 

Over  the  second  left  interspace  pulsation  of  the 
pulmonary  artery,  sometimes  systolic,  sometimes 
diastolic  {see  p.  104j,  and  of  the  left  auricle,  always 
presystolic,  must  be  sought  for ;  and  a  thrill  may 
not  rarely  be  detected  in  the  pulmonary  artery  in 
certain  diseases,  especially  in  exophthalmic  goitre 
{see  further  under  Auscultation,  p.  151). 

Over  the  aorta,  where  it  approaches  the  front  of  the 

*  Sansom,  "  Diagnosis  of  Diseases  of  the  Heart,"  p.  128. 


112  CiRC  ULA  TOR  V   SVS  TEM. 

thorax  near  the  sternum  in  the  second  right  interspace 
and  behind  the  second  right  costal  cartilage,  pulsations 
or  thrills  may  also  be  detected,  whilst  in  cases  of 
aneurysm  of  the  root  of  the  vessel  or  of  the  ascend- 
ing part  of  its  arch,  a  characteristic  expansile  pulsa- 
tion can  sometimes,  though  by  no  means  always,  be 
observed.  The  time  of  occurrence  of  all  these  phe- 
nomena must  be  given  with  reference  to  the  apex  beat. 

At  the  root  of  the  neck  palpation  will  fre- 
quently enable  one  to  identify  a  pulsating  vessel,  and 
so  clear  up  a  doubtful  diagnosis.  When  pulsation 
occurs  in  the  episternal  notch  one  should,  if  possible, 
try  to  push  the  finger  below  the  pulsating  vessel. 
By  so  doing  one  may  be  saved  the  inconvenience  of 
diagnosing  an  aortic  aneurysm  when  the  patient  has 
merely  an  abnormal  origin  of  his  right  subclavian. 

By  pressing  the  finger  firmly  down  from  the  epi- 
sternal notch  behind  the  upper  part  of  the  sternum — 
due  care  being  exercised  not  to  cause  the  patient 
too  much  discomfort — a  co'inmencing  dilatation  of 
the  transverse  arch  of  the  aorta  may  be  identified 
in  time  to  allow  of  effectual  treatment  being  carried 
out,  since  in  health  the  aorta  lies  at  so  low  a  level 
that  its  pulsation  can  scarcely  be  detected  by  this 
manoeuvre. 

Another  method  of  discovering  an  early  dilatation 
of  the  aorta,  when  the  under-side  of  the  arch  is  the 
part  involved,  has  been  described  by  Surgeon-Major 
Oliver  and  others  under  the  name  of  tracheal 
tug'g'iiig'.  The  explanation  of  this  phenomenon 
depends  upon  the  fact  that  in  passing  from  the 
trachea  to  the  lung  the  left  bronchus  lies  just  below 
the  arch  of  the  aorta,  and  consequently  each  time 
that  the  aorta  is  distended  the  aneurysmal  dilatation 
pushes  the  bronchus  downwards  before  it,  and  the 
latter  drags  in  turn  upon  the  trachea,  causing  it  to 
descend   at   each   beat   of  the   heart.     By   standing 


Pa  LP  A  TION. 


113 


behind  the  patient  and  pressing  the  cricoid  lightly 
upwards  with  the  finger-tips  of  both  hands,  whilst  tlie 
patient  keeps  his  mouth  closed  and  elevates  his  chin, 
the  downward  tug  can  in  many  cases  be  detected  with 
great  facility. 

Pulsations  and  thrills  may  be  observed  in  the 
carotids,  and  must  be  fully  investigated  by  palpa- 
tion. Occasionally  a  thrill  may  be  felt  in  the  supra- 
clavicular fossa,  where  the  subclavian  artery  crosses 
the  apex  of  the  lung.  It  may  indicate  a  constriction 
of  the  vessel  resulting  from  pleuritic  adhesion,  or 
disease  of  the  lung  itself. 

Ill  the  epig-astriiiin  the  fingers  should  be 
pressed  gently  but  firmly  upwards  under  the  left 
costal  margin  when  pulsation  of  the  right  ventricle  is 
suspected.  By  this  means  it  may  be  readily  differen- 
tiated from  pulsation  of  the  liver. 

When  the  liver  exhibits  expaiiisile  pulsa- 
tion, owing  to  backward  pressure  in  the  veins  due 
to  tricuspid  incompetence,  the  whole  organ  will  be 
found  to  be  affected,  and  in  most  cases  the  exj)ansile 
character  of  the  movement  can  be  distinctly  made 
out.  When  the  right  ventricle,  by  pressing  on  it 
during  systole,  causes  epigastric  pulsation,  the  move- 
ment can  rarely  be  detected  except  in  a  part  of  the 
liver.  In  cases  of  doubt  as  to  the  nature  of  epigastric 
pulsation,  a  change  in  the  patient's  posture,  particu- 
larly if  he  is  made  to  assume  a  knee-elbow  position, 
frequently  clears  up  the  difficulty. 

SECTION    IV.— PERCUSSION. 

Theory. — When  a  sharp  tap  is  given  over  any  part  of  the 
body,  the  underlying  structures  either  resound  to  the  blow  or 
merely  respond  with  a  dull  thud  like  that  which  a  lump  of 
putty  would  yield  under  similar  conditions.  The  former  bodies 
are  described  as  resonant,  the  latter  as  dull,  on  percussion.  The 
resonant  structures  in  the  body  are  the  air-containing-  organs 
and  the  bones.     The  latter  emit  a  sound  when  struck,  which  is 


114  Circulatory  System. 

totally  distinct  from  that  yielded  by  the  viscera  which  contain 
air.  It  is  known  as  the  osteal  percussion  sound,  and  is  typi- 
cally heard  when  the  skull  is  lightly  tapped.  The  cause  of 
resonance  is  that  such  bodies  as  possess  it  are  able  to  \'ibrate 
with  more  or  less  regularity.  In  the  case  of  the  bones  this 
power  of  regular  vibration  is  due  to  the  elasticitj'-  of  the 
osseous  substance  ;  in  the  case  of  a  hollow  viscus,  such  as  the 
stomach,  colon,  or  small  intestine,  it  depends  on  the  periodic 
oscillations  of  the  contained  air  columns,  and  on  the  tension  of 
the  limiting  stomach  or  bowel  wall ;  in  the  lung  the  factors 
become  more  complex,  for  we  have  to  deal  with  very  greatly 
subdivided  air  columns,  and  the  septa  are  under  a  considerable 
degree  of  tension.  Since  the  exact  quality  of  the  resonance 
which  is  produced  is  influenced  by  the  amount,  disposition, 
pressui'e,  and  subdivision  of  the  included  air,  and  also  by  the 
tension  of  the  walls  and  septa  of  the  "siscus,  it  is  evident  that 
each  organ  will,  on  percussion,  give  out  a  sound  which  is 
fairly  characteristic.  With  a  comparatively  simple  air-space 
such  as  the  stomach  presents,  the  resonance  resembles  that  of 
a  drum,  and  is  therefore  described  as  tympanitic  ;  in  the  lung, 
on  the  other  hand,  the  innumerable  septa  so  break  up  the  air- 
space that  the  resonance  acquires  a  peculiar  and  quite  distinctive 
character.  There  is  no  other  sound  which  bears  any  close  resem- 
blance to  it,  hence  it  is  simply  known  as  normal  lung  resonance, 
and  the  student  must  learn  to  recognise  it  from  frequent  practice. 
The  depth  of  tissue  which  is  thrown  into  vibration  by  the 
percussion  stroke  depends,  when  other  things  are  equal,  on  the 
force  of  the  blow.  When  the  chest  wall  over  two  regions  of 
the  lung  is  percussed  with  equal  force,  and  when  in  one  case  a 
considerable  depth  of  lung  tissue  underlies  the  point,  whilst  in 
the  other  only  a  thin  layer  of  lung  intervenes  between  the 
surface  and  a  subjacent  solid  organ,  a  characteristic  difference 
is  observed  in  the  sound  produced,  just  as,  when  a  big  drum 
and  a  little  one  are  struck,  they  emit  perfectly  distinct  sounds. 
The  difference  of  sound  depends  on  several  factors,  the  import- 
ant points  to  note  being  that  the  thick  layer  of  lung  and 
the  big  drum  emit  a  sound  which  lasts  longer  and  conveys  an 
impression  of  greater  resonance  and  lower  pitch.  The  thin 
layer  of  lung  and  the  little  drum,  on  the  other  hand,  yield  a 
sound  of  shorter  duration,  of  less  resonance,  and  of  higher 
pitch.  The  exact  pitch,  however,  is  always  somewhat  indeter- 
minate, as  it  is  compounded  of  a  mixture  of  several  indepen- 
dent, more  or  less  tone-like,  sounds  and  their  overtones.  For 
practical  purposes  we  may  describe  the  resonance  of  a  thick 
layer  of  lung  as  "/?^ZZ,"  and  that  of  a  thinner  layer  as 
"  emptier^''  the  words  being  employed  in  a  general,  but  suffi- 


Percussion.  115 

ciently  intelligible  sense,  to  describe  the  complex  impression 
which  the  observer  readily  recognises,  but  which,  under  the 
conditions  of  clinical  work,  baffles  exact  analysis. 

AVhen  a  very  light  blow  is  delivered  the  resonance  of  only 
a  thin  layer  of  the  subjacent  lung  is  elicited,  and  the  sound 
produced  is  comparatively  empty,  even  although  a  thick  part 
of  the  lung  lies  below  the  point  of  percussion.  Hence  it 
follows  that  the  presence  of  a  solid  organ  underneath  the  lung 
will  only  render  the  resonance  "emptier"  when  it  approaches 
sufficiently  near  the  surface  to  encroach  uj)on  the  layer  which 
is  being  set  in  vibration.  A  firmer  stroke  would  throw  a 
thicker  layer  into  vibration,  and  in  this  case  a  solid  body 
advancing  from  below  would  sooner  reach  the  vibrating  area, 
and  render  the  resonance  emptier.  In  other  words,  when  the 
object  aimed  at  is  to  detect  the  presence  of  an  organ  which  lies 
underneath  a  thick  layer  of  lung,  then  the  percussion  stroke 
should  be  firm.  If,  on  the  contrary,  the  object  of  inquiry  is 
to  ascertain  the  spot  where  a  resonant  viscus  terminates,  more 
especially  if  it  grows  thin,  wedgewise,  as  its  border  is  ap- 
j)roached,  it  is  evident  that  the  end  in  view  will  be  best 
achieved  by  very  light  percussion,  since  by  this  procedure  the 
resonance,  though  comparatively  empty,  remains  of  uniform 
quality  until  the  edge  of  the  organ  is  reached,  when  it  is  re- 
placed by  an  absolutely  dull  thud. 

This  is  diagramatically  represented  in  the  accompanying 
figure  (Fig.  18),  where  it  is  easily  seen  that  with  firm  per- 
cussion the  resonance  begins  to  grow  emptier  at  h  and 
gradually  alters  thereafter  at  every  point  till  the  emptiness 
is  completed  at  d,  whilst  with  lighter  percussion  the  resonance 
remains    uniform  although     ^^..i,___  ^___«=« 

comparatively  empty  until     ^         j     *       ^^^ 
c  is  reached,  when  it  rapidly     ^       |~  °       ^^^^ 
gives  place  to  absolute  dul-     ^^^^     I  ^^^^  • 

ness,  and  thus  the  final  ex-      ^^^^^  I  ^^^^^ 

tinction  of  resonance  is  much     ^^|^^M~-  -       ^^^^1 
more  readily  appreciated.  ^^^^^H  ^^^^l__ 

One    other    preliminary      i^^^^^*       ^ 
matter  must  be  referred  to.  ^' 

If  the  tight  membrane  which  is  stretched  over  a  drum  be 
covered  with  a  soft  solid,  the  sound  which  it  yields  is  muffled, 
and  in  like  manner  if  a  solid  organ  overlies  an  air-containing 
one,  the  resonance  of  the  latter  will  be  thereby  viuffled,  and 
the  more  softly  the  percussion  stroke  is  delivered  the  more 
marked  will  the  muffling  become.  A  soft  stroke  is  particularly 
necessary  when  the  solid  organ  is  thin,  or  when  its  border 
requires  to  be  accurately  defined. 


ii6  Circulatory  System. 

Methods  of  pei'ctisisioii. 

When  percussion  was  first  introduced,  the  tap  was 
delivered  directly  on  the  patient's  skin  without  the 
interposition  of  any  substance  over  the  point  struck. 
This  method,  known  as  direct  perciis^^ion,  is  now 

seldom  used  except  on  the  clavicles,  which  in  ex- 
amination of  the  lungs  are  lightly  taj^ped  by  the 
observer's  finger-tip.  In  order  to  obtain  better 
resonance,  as  well  as  with  a  view  to  the  patient's 
comfort,  various  materials  were  subsequently  inter- 
posed between  his  skin  and  the  ])ercussing  finger.  A 
flat  plate  of  bone  or  ivory,  of  such  a  size  and  shape  as 
to  be  readily  applied  and  closely  adapted  to  the  surface 
of  the  chest,  is  frequently  employed,  and  is  called  a 
pleximeter.  In  some  instances,  when  the  curvature 
of  the  surface  renders  the  application  of  such  an  in- 
strument difiicult,  a  short  rod  of  bone  or  vulcanite, 
set  pillarwise  on  the  region  to  be  percussed,  is  em- 
ployed. A  very  good  pillar  pleximeter  may  be 
improvised  by  utilising  a  short  piece  of  good  cork, 
such  as  is  used  for  closing  specimen  tubes.  It  con- 
veys the  impact  well,  and  itself  emits  but  little 
sound  when  struck.  Most  physicians,  however, 
prefer  to  make  use  of  the  middle  or  fore  finger  of 
their  left  hand  as  a  pleximeter,  and  the  preference  is 
due  not  only  to  the  fact  that  it  can  be  readily  adapted 
to  almost  any  surface,  but  also  that  it  often  conveys 
information  additional  to  that  obtained  by  the  per- 
cussion sound,  as  it  takes  cognisance  of  the  different 
degrees  of  resistance  which  the  tissues  offer  to  the 
percussion  stroke. 

Sometimes  a  small  rubber-tipped  hammer,  known 
as  a  plessor,  takes  the  place  of  the  percussing  finger, 
and  is  occasionally  of  service ;  but  as  a  rule  the  finger 
should  be  preferred. 

The  ordinary  method,  then,  of  percussion  is  con- 
ducted in  the  following  manner  : — The  middle  finger 


Percussion.  iiy' 

of  the  left  hand  is  placed  firmly  on  the  part  which  is 
to  be  percussed,  and  is  adapted  to  any  inequalities  of 
surface,  so  that  no  air-space  is  interposed  between  it 
and  the  skin.  The  back  of  its  middle  phalanx  is 
then  struck  with  the  tip  of  the  middle  iinger  of  the 
ricfht  hand.  The  stroke  should  be  delivered  from  the 
wrist  and  finger  joints,  not  from  the  elbow,  and  the 
percussing  finger  should  be  so  bent  that  when  the 
blow  is  delivered  its  terminal  phalanx  is  at  right 
angles  to  the  metacarpal  bones,  and  strikes  the 
pleximeter  perpendicularly.  Whenever  the  blow^  has 
been  given,  the  striking  finger  must  be  raised,  lest  it 
should  impair  the  vibrations  it  has  excited,  just  as  the 
hammers  of  a  piano  fall  back  from  the  wires  as  soon 
as  they  have  been  struck.  In  cases  where  the  per- 
cussion requires  to  be  more  fi.rm,  several  fingers  may 
be  used ;  but  it  is  better,  whenever  possible,  to 
employ  only  one  percussing  finger.  In  some  cases  a 
modification,  known  as  flicking  percussion,  is  useful, 
and  this  is  particularly  valuable  in  the  examination 
of  the  abdomen,  where  the  method  is  more  fully 
described  (p.  57). 

There  are  two  cardinal  rules  which  should 
always  be  remembered  when  percussion  is  being 
carried  out.  The  first  is  that  in  defining  the 
boundaries  between  resonant  and  non-resonant  or 
less-resonant  organs,  the  percussion  should  invariably 
be  performed  from  the  former  towards  the  latter. 
The  second  is  that  the  longer  axis  of  the  plexi- 
meter should  be  parallel  to  the  edge  of  the  organ 
whose  delimitation  is  being  attempted,  and  the  line 
of  percussion  should  be  at  right  angles  to  that  edge. 

Percussion  of  the  heart. 

The  objects  which  are  aimed  at  in  percussion  of 
the  heart  are  twofold  ;  firstly,  to  ascertain  the  size 
and  position  of  the  organ  as  a  w^hole,  and  secondly,  to 
determine  how  much  of  it  is  uncovered  by  lung  and 


I  1 8  CiRC  ULA  TOR  V    SVS  TEM. 

lies  against  the  chest  wall.  Since  for  the  most  part 
the  heart  is  surrounded  by  resonant  lung,  but  does  not 
lie  so  deeply  as  to  be  out  of  reach  of  a  firm  percussion 
stroke,  one  can  delimit  its  boundaries  with  a  consider- 
able degree  of  accuracy  by  observing,  as  one  percusses 
towards  the  cardiac  region,  the  points  at  which  the 
lung  resonance  begins  to  grow  emptier.  In  two  areas 
this  cannot  be  achieved.  At  the  base  of  the  heart 
the  roots  of  the  great  vessels  produce  a  dulling  or 
emptying  of  the  lung  resonance  which  cannot  be  dis- 
criminated from  that  caused  by  the  heart,*  whilst  the 
lower  border  of  the  viscus  is  in  relation  to  non- 
resonant  liver,  which  yields  on  percussion  the  same 
dull  thud  that  the  heart  itself  does.  It  is  also  im- 
portant to  know  how  much  of  the  heart  is  quite 
uncovered  by  lung.  This  is  learned  by  percussing 
from  the  points  where  the  resonance  is  impaired 
towards  the  borders  of  the  lungs  where  they  overlie 
the  heart,  employing  a  light  stroke  and  observing 
when  the  slight  resonance  is  replaced  by  absolute 
dulness.  The  area  in  which  the  heart  is  uncovered 
by  the  lung  and  lies  directly  against  the  chest  wall 
is  called  the  area  of  superficial  or  absolute 
cardiac  dulness;  the  surrounding  region  where 
the  heart  is  covered  by  a  layer  of  lung  is  known  as 
the  area  of  «leep  or  comparative  cardiac  dul- 
ness, and  its  outline  corresponds  approximately  to 
the  anatomical  outline  of  the  heart.  The  accompany- 
ing diagram  (Fig.  19),  which  represents  an  antero- 
posterior section  of  the  chest  in  the  left  parasternal 
line,  will  explain  the  sequence  of  phenomena  which  are 
observed  on  percussion.  At  a  the  resonance  is  full, 
at  h  it  begins  to  grow  emptier,  and  continues  to  do  so 
till  d  is  reached,  when  the  sound  becomes  absolutely 

*  The  vagueness  of  the  results  obtained  in  this  region  is  still 
further  increased  by  the  * '  sounding-board "  property  of  the 
sternum. 


Percuss  ION. 


119 


dull,  and  continues  so  over  the  uncovered  surfaces  of 
the  heart  and  liver  until  e  is  reached,  when  the 
resonance  of  the  stomach,  though  muffled,  may  be 
distinctly  detected,   and  at  /  the    muffled  resonance 


Fig.  10. — Aiitero-posterior  section  of  thorax  near  the  left  parasternal  line. 
(Slightly  modified  from  Lusclika.) 

gives  place  to  the  full  tympanitic  stomach  note.  The 
percussion  stroke  must  be  firm  in  passing  from  a  to 
6,  light  from  c  to  d,  and  light  also  as  one  percusses 
upwards  from  g  to  e. 

Deep  <1iiluess. — By  firm  percussion,  then,  the 
right,  the  left,  and  that  part  of  the  upper  border  of 
the  heart  which  lies  to  the  left  of  the   roots   of   the 


I20  Circulatory  System. 

great  vessels  can  be  defined.     To  do  this,  percussion 
is  performed  in  two  directions  :  firstly,  down  a  vertical 
line  far  enough  from  the  middle  plane  to  be  quite  to 
the  left  of  the  great  vessels,  but  not  so  far  out  as  to 
miss  the  upper  border  of  the  heart  altogether — the 
left  parasternal  line,  or  one  a  shade   internal  to  it, 
fulfils  these  requirements ;  *    secondly,  percuss   from 
right  to  left  along  a  line  as  far  down  the  chest  as 
possible,  but  yet  clear   of  any  trace  of  hepatic  dul- 
ness ;    and  also   along  the  continuation  of   this  line 
to   the  left   of  the  heart,   but    this    time    percussing 
from  left  to  right.     In  the  vertical  line  one  should 
begin    at    the    first    interspace,    comparing    its    re- 
sonance   with    that    of    the    second,    and   this    with 
the  third,   and   so  continuing  downwards    until    the 
first  trace   of  impaired  resonance  is   observed.      One 
then    knows    that   the    boundary    of    the    heart    has 
been   reached.     But   the  dulness  may  also  be  present 
at  the  level  of  the  rib  above  the  interspace  in  which 
it  was  detected,   and  therefore  the  percussion  sound 
of  this  rib  must  be  compared   with   that  of  the  one 
next  above  it.     If  the  resonance  of  the  lower  of  the 
two  be  less  full  than  that  of  the  upper,  one  knows 
that   the    outline  of   the   heart   lies  behind  it.      The 
reason  why  rib  is  compared  with  rib,  and  interspace 
with  interspace,  is  that  otherwise  the  alternate  pre- 
sence and  absence  of  the  osteal  resonance,  according 
as  rib  or  interspace    is   being   percussed,    introduces 
an    element  of    unnecessary   confusion.     Before  per- 
cussing the  right  border  of  the  heart,  the  upper  limit 
of  deep  hepatic  dulness  between  the  right  parasternal 

*  In  a  paper  entitled  "  Om  Perkussion  af  Hjertet,"  in  the 
"Festskrift  for  Prof.  Heiberg,"  Laaclie  advises  somewhat  light 
percussion  from  above  downwards  over  the  left  half  of  the 
sternum  in  order  to  delimit  the  upper  border  of  the  heart,  and 
quotes  a  number  of  cases  in  which  he  has  practised  the  method 
successfully.  The  writers  have  tried  this  procedure  in  several 
instances,  and  are  satisfied  that  at  times  it  is  of  decided  value. 


Percussion.  121 

and  the  right  mammary  lines  must  be  determined,  just 
as  the  upper  border  of  the  heart  was.  When  this  has 
been  done,  the  right  border  must  be  defined  by  per- 
cussing from  the  right  mammary  line  towards  the 
sternum  along  the  rib  or  interspace  above  the  level 
at  which  the  first  traces  of  hepatic  dulness  were 
observed. 

Although  the  lower  border  of  the  heart  cannot 
be  percussed  out,  a  sufficiently  close  approximation 
to  it  is  attained  by  drawing  a  line  from  the  upper 
limit  of  deep  hepatic  dulness,  which  has  already  been 
determined  and  which  is  usually  found  at  the  level 
of  the  fourth  interspace  or  fifth  rib,  to  the  apex,  whose 
position  has  previously  been  fixed  by  palpation. 

By  percussing  in  the  fourth  interspace  from  the 
left  lung  towards  the  heart,  one  is  able  to  define  the 
left  border  with  considerable  precision,  and  in  cases 
where  it  is  desirable  to  obtain  further  points  one  can 
percuss  in  various  other  lines  perpendicular  to  the 
border,  from  the  lungs  towards  the  heart.  The  student 
must  not  confuse  the  slight  muffling  of  the  lung 
resonance  which  occurs  when  he  arrives  over  the 
pectoral  muscles  with  the  deep  dulness  of  the  heart. 
It  will  be  found  that  in  an  average  healthy  chest  the 
percussion  limits  of  the  heart  are  as  follow  (Fig.  20) : 

Upper  border  (in  left  parasternal  line),  at  the 
third  rib  or  upper  border  of  the  third  interspace. 

Rig-lit  border  (at  level  of  fourth  rib)  is  just  to 
the  right  of  the  right  lateral  sternal  line.  If,  how- 
ever, the  lungs  are  somewhat  voluminous,  it  may  be 
impossible  to  detect  the  impairment  of  resonance  at 
this  point,  and  behind  the  sternum  accurate  observa- 
tions are  not  very  easy  to  make,  as  the  sternum  acts 
as  a  sounding-board,  and  collects  vibrations  from  all 
the  structures  behind  it,  whether  they  lie  directly 
beneath  the  point  of  percussion  or  are  at  some  dis- 
tance from  it. 


122  Circulatory  System, 

L<eft.  toorder  (at  level  of  fourth  interspace),  a 
shade  internal  to  the  mammary  line.  If  it  is  per- 
cussed at  a  higher  level  it  will  be  found  to  curve 
round  so  as  to  merge  insensibly  with  the  upper 
border. 

The  superficial  diiliiess  of  the  heart,  which 


Fig.  20. — Superficial  and  deep  dulness  of  normal  heart  and  liver. 

depends  on  the  position  of  the  borders  of  the  lungs, 
must  be  determined  by  light  percussion.  To  ascertain 
the  upper  border,  one  should  percuss  downwards 
between  the  left  lateral  sternal  and  left  parasternal 
lines.  The  left  border  is  found  by  percussing  from 
the  left  mammary  towards  the  middle  line  along 
the  fourth  intercostal  space,  or  fifth  rib  ;  the  right, 
by  light  percussion  at  the  same  level,  beginning  to 
the  right  of  the  sternum.     In  health  it  will  be  found 


Percussioiw  123 

that  the  upper  limit  is  at  the  level  of  the  fourth 
rib.  The  left  at  its  upper  end  is  rather  more  than 
half  an  inch  within  the  left  border  of  the  heart  as 
already  determined  ;  at  its  lower  end  it  is  decidedly 
nearer  that  border,  and  may  extend  outwards  almost 
to  the  apex  beat.  The  right  limit  does  not  correspond 
with  the  edge  of  the  right  lung,  which,  placed  as  it  is 
behind  the  sternum,  cannot  be  exactly  defined,  but 
lies  in  the  left  lateral  sternal  line,  where  it  extends 
from  the  fourth  to  the  sixth  costal  cartilage.  The 
left  limit  curves  gradually  round  to  be  continued  into 
the  upper,  the  latter  joins  the  right  limit  at  an  angle. 
The  space  is  therefore  of  triangular  outline,  but  the 
left  side  of  the  triangle  is  not  straight  but  convex 
outwards.  The  lower  side  of  the  triangle  cannot  be 
defined  by  percussion,  but  corresponds  with  the 
inferior  border  of  the  heart,  and  is  marked  out  in  the 
manner  already  described. 

Lying,  as  they  largely  do,  behind  the  sternum, 
the  dulness  due  to  the  great  vessels  can  seldom  be 
made  out  with  precision.  If,  however,  there  is 
aneurysmal  dilatation  of  the  ascending  aorta,  a  dull 
area  can  be  mapped  out.  It  is  continuous  below  with 
that  of  the  heart,  above  it  bulges  outwards  to  the 
right  of  the  sternum  at  the  level  of  the  second  inter- 
space and  adjacent  ribs  ;  whilst  the  sound  produced  by 
percussion  of  the  manubrium  sterni  is  also  rendered 
much  less  resonant  or  even,  in  cases  where  the 
aneurysm  is  large,  absolutely  dull  (Fig.  21). 

In  diseased  conditions  both  the  relative  and  the 
absolute  cardiac  dulness  may  be  altered  in  size  or  in 
position. 

When  tlie  relative  or  deep  dulness  is 
enlarg'ed,  the  condition  may  be  due  either  to  disease 
of  the  heart  and  pericardium,  or  to  morbid  condi- 
tions in  the  surrounding  viscera.  If  the  dulness  in 
the  left  parasternal  line  be  found  to  extend  upwards 


124  Circulatory  System. 

into  the  second  interspace  or  higlier,  without  any 
corresponding  upward  displacement  of  the  lower 
boundary,  such  as  would  be  present  were  the  heart 
dislocated  upwards  as  a  whole,  and  in  the  absence  of 


Fig.  21.— Aortic  aneurysm. 

disease  of  the  lung,  the  condition  is  usually  due  to 
pericardial  effusion.  Aneurysm  of  the  descending 
arch  of  the  aorta  has  been  known  to  cause  dulness 
in  this  region,  but  this  effect  is  only  produced  in  the 
rare  instances  where  the  aneurysm  passes  far  forwards. 
Most  aortic  aneurysms  are  found  farther  to  the  right. 
If  the  relative  dulness  extends  to  the  left  of  the 
apex  heat,  provided  the  lung  and  pleura  be 
healthy,  we  have  to  do  with  pericardial  effusions ;  and 
in  this  case  the  right  border  will  be  found  at  a 
considerable  distance  to  the  right  of  the  sternum — it 
may  be  as  far  as  the  right  parasternal  line.     If  the 


Percussion. 


^25 


-~. --) 


\  Vv.8- 


^  V 


\   10 


9  J.   \ 

\  to/ 


Fi-  22  -Diagram  to  illustrate  the  effect  of  dilatation  of  the  right  and  left 
°  sides  of  the  heart  respectively.     (Gee  afttr  v.  Duscli.) 

rontinuous  heavy  outline,  normal  heart ;  dotted  line  dilatation  of  right  side ; 
Continuous  neaN  j  oui^  ^_^,^^^^  outhue,  dilatation  of  left  side. 

cardiac  dulness  extends  to  the  left  of  the  mammary 
line,  but  does  not  reach  beyond  the  situation  ot  the 


126 


Circulatory  System. 


apex  beat,  the  condition  is  probably  due  to  dilatation 
and  hypertrophy  of  the  left  ventricle,  unless  the 
heart  is  bodily  dislocated  to  the  left  by  some  such 
cause   as  massive  pleural  effusion  on  the  right  side. 


Fig.  23.— Dilatation  and  hypertrophy  of  left  side  of  heart. 

If  the  dulness  extends,  in  the  absence  of  lung  disease, 
pleurisy,  or  pericardial  eff'usion,  more  than  about  a 
finger's  breadth  to  tlie  right  of  the  steriiiiiii,  one 

is  justified  in  concluding  that  the  right  heart  has 
become  dilated  (Fig.  22).* 

Since  dilatation  and  hypertrophy  of  the  left 
ventricle  not  only  displace  the  left  border  outwards 
but  cause  depression  of  the  apex,  the  percussion  out- 
line of  such  a  heart   will  become  conical  (Fig.   23), 

*  The  auricle,  whose  boundary  is  thus  determined,  is  dilated ; 
the  ventricle  is  usually  both  dilated  and  hypertrophied. 


Percussion. 


127 


whilst  dilatation  of  the  right  side,  by  causing  the 
cardiac  dulness  to  extend  too  far  to  the  right  without 
greatly  affecting  the  level  of  the  apex,  renders  the  dull 
area  more  square  than  usual  (Fig.  24). 


Fig.  24.— Dilatation  of  right  side  of  heart. 


The  dulness  which  one  finds  in  pericarditis 
with  effusion  or  in  hydropericardium  varies  with 
the  amount  of  fluid  which  is  present,  but  in  well- 
marked  cases  is  pear-shaped,  with  the  broader  end 
downward  and  the  upper  end  higher  than  the  ordinary 
upper  limit  of  dulness  (Fig.  25). 

The  chief  causes  outside  the  heart  and  pericardial 
sac  that  produce  an  increase  in  the  area  of  cardiac 
dulness  are  due  to  diseases  of  the  lungs  and  pleura. 
Here  one  may  find  consolidation  or  tumour  of  the 
lung,  or  pleural  efiusion ;    or  a  cirrhotic  contraction 


128  Circulatory  System. 

of  the  lung,  or  the  binding  of  it  back  by  pleuritic 
adhesions,  may  leave  more  than  usual  of  the  front 
of  the  heart  exposed,  or  at  least  near  the  surface. 
In  comparatively  rare  instances  the  heart  is   pushed 


Fig.  25. — Pericardial  effusion. 

forwards  by  a  tumour  or  aneurysm  in  the  posterior 
mediastinum. 

The  relative  ditliieiss  of  tlie  heart  may 
be  diiiiiiiishecl  in  cases  where  the  heart  is  un- 
usually small,  or  the  lungs  so  emphysematous  as  to 
interpose  a  layer  of  pulmonary  tissue  that  is  thick 
enough  to  carry  the  margins  of  the  heart  beyond  the 
sphere  of  action  of  the  percussion  stroke.  As  a 
corollary  to  this,  it  should  be  observed  that  if,  when 
the  lungs  are  emphysematous,  the  heart's  dulness 
reaches  fully  up  to  the  normal  limits  one  is  justified 


Pkrcussjon. 


129 


in  assuming  that,  as  a  matter  of  fact,  it  oversteps 
these  limits.  Air  in  tlie  pleural  cavity  will  also 
diminish  the  area  of  dulness,  whilst  in  pneumoperi- 
cardium it  is  often  completely  abolished. 


Fig.  26.— Displacement  of  heart  upwards. 

It  is  well  to  preserve  a  note  of  the  breadth,  in 
inches,  of  the  cardiac  dulness  at  the  level  of  the  fourth 
rib  or  interspace. 

The  area  of  absolute  or  superltcial  dul- 
ness is  of  less  importance,  being  much  affected  by 
the  state  of  the  lungs.  It  is  thus  increased  when  they 
are  retracted,  decreased  or  almost  abolished  when  they 
are  distended^  as  in  advanced  emphysema ;  otherwise, 
it  is  altered  by  the  same  conditions  and  in  somewhat 
the  same  manner  as  the  area  of  relative  dulness. 

The   situation   of   the   area   of  cardiac  dulness  is 


I30 


CiRcuLA  TOR  J '  System. 


naturally    altered    by    eliaiig'es   in   llie   position 

of  the  heart.  These  result  from  its  displacement 
by  the  pressure  or  traction  of  other  organs,  or  from 
developmental   anomalies.     Thus    in   dexiocardia  the 


Fig.  27. — Displacement  of  heart  ami  liver  in  cniiiliysenia. 


heart  is  placed  with  its  apex  to  the  right,  and  the 
area  of  dulness  is  then  the  mirror  image  of  what  is 
usually  found. 

In  cases  of  ascites  or  of  massive  abdominal 
tumour  the  heart  is  pushed  upwards  under  the 
lungs.  Hence  its  area  of  dulness  is  placed  higher 
than  usual,  and,  owing  to  the  thickness  of  overlying 
lung,  may  be  unusually  difficult  to  map  out  (Fig,  26). 
Tumours  of  the  liver  displace  the  heart  upwards  and 
to  the  left.  Pulmonary  emphysema  thrusts  the  heart 
downwards  (Fig.  27),  pleural  eifusion  drives  it  towards 


Percussion.  131 

the  sound  side  of  the  chest  (Figs.  28,  29),  whilst 
cicatricial  contraction  of  the  left  lung  often  draws  it 
upwards  and  to  the  left. 

In  certain  cases  of  pericardial  effusion  it  is  stated 


Fig.  28. — Displacement  of  heart  in  right-sided  pleural  effusion. 

that  a  small  dull  area  can  be  found  posteriorly  near 
the  angle  of  the  left  scapula.  The  phenomenon  is  of 
doubtful  value,  and  has  not  been  very  satisfactorily 
accounted  for.  Those  who  wish  to  study  it  must  refer 
to  larger  works,  or  to  special  papers  on  the  subject.* 

Whilst  the  student  is  percussing  the  heart,  he 
should  attend  not  only  to  the  resonance  which  is 
elicited  but  also  to  the  sense  of  resistance  of 
the  underlying  tissues   which  the  pleximeter  finger 

*  Sansom,    "Diagnosis   of  Diseases   of  the   Heart,"  p.    159; 
Ewart,  Brit.  Med.  Journal,  March  21,  1896,  p.  717. 


132 


Circulatory  System. 


experiences.  By  this  means  he  may  often  form  a 
shrewd  guess  of  the  nature  of  the  subjacent  structures. 
For  example,  a  well-trained  finger  will  detect  decidedly 
greater  resistance  over  a  dull  area  when  the  dulness 


Pig,  29.— Displacement  of  heart  in  left-sided  pleural  effusion. 


is  caused  by  fluid,  as  in  pleurisy  or  hydropericardium, 
than  when  it  is  produced  by  a  solid  organ  like  the  heart 
or  a  pneumonic  lung. 

SECTION    v.— AUSCULTATION    OF    THE 
HEART   AND   VESSELS. 

1.  The  stethoscope.  —  Auscultation,  though 
sometimes  performed  by  the  direct  application  of  the 
ear  to  the  chest  wall,  is  generally  conducted  by  means 
of  a  stethoscope,  and  the  student  cannot  take  too 
great  pains  to  choose  a  good  one. 


A  use  UL  TA  TION.  \  3  3 

Stethoscopes  are  of  two  types,  single  and  binaural. 
Each  of  these  has  its  special  advantages  and  disad- 
vantages. Binaural  instruments  are  particularly 
serviceable  in  the  examination  of  children  and  of 
patients  too  ill  to  be  much  disturbed.  Single  ones, 
although  they  conduct  less  loudly,  are  relatively 
rather  more  sensitive  to  high-pitched  sounds.  In  the 
choice  of  a  binaural,  one  should  avoid  instruments 
with  unnecessary  joints  and  loose  parts,  or  with 
woven  tubes.  The  chest  piece  should  not  be  very 
large,  nor  made  of  metal ;  vulcanite  is  not  so  chilly, 
and  is  quite  easily  cleaned.  It  is  obvious  that  unless 
the  ear  fittings  are  suitably  shaped,  much  discomfort 
will  be  produced. 

In  choosing  a  single  stethoscope  much  depends  on 
the  grain  of  the  wood  ;  some  woods,  such  as  oak,  will 
be  found  to  conduct  better  than  others.  The  chest 
piece  should  be  of  moderate  size,  so  that  it  may  be 
in  complete  apposition  with  the  chest  wall  even  when 
the  patient's  ribs  are  prominent.  The  ear  piece  should 
be  selected  so  as  to  ht  the  ear  with  comfort.  The 
instrument  should  have  no  loose  parts.  A  good 
rough  and  ready  test  of  the  efficiency  of  a  stetho- 
scope is  to  listen  with  it  to  the  ticking  of  a  watch, 
and  to  select  the  instrument  which  conducts  the 
sound  best.  In  practice  the  student  must  be  very 
careful  not  to  press  heavily  on  the  patient  when 
using  a  single  stethoscojje. 

The  phonendoscope  has  not  yet  secured  any  very 
general  recognition.  This  may  be  due  in  part  to 
the  fact  that  though  it  conveys  low-pitched  sounds 
with  great  clearness,  it  does  not  conduct  high  tones 
so  well  as  the  ordinary  stethoscope ;  and,  since 
high  tones  are  peculiarly  characteristic  of  many 
morbid  conditions  in  the  lungs,  it  is  obvious 
that  its  use  for  clinical  purposes  is  seriously 
limited 


134  Circulatory  System. 

2.  The  cardiac  cycle  and  siiiTace  anatomy 
of  the  valves  and  vessels. 

Tn  order  to  understand  the  various  sounds  which 
can  be  heard  by  listening  to  the  heart  through  the 
chest  wall,  a  clear  conception  of  the  events  which 
occur  during  a  cardiac  cycle  is  essential. 

After  the  completion  of  a  beat  the  auricles  and 
ventricles  are  both  relaxed.  Thereafter  the  auricles 
contract,  forcing  their  contents  through  the  cuspid 
valves  into  the  ventricles,  and  filling  them.  The 
ventricles  then  contract  in  turn,  expelling  the  blood 
into  the  vessels,  whilst  the  auricles  commence  to 
relax  and  become  refilled  with  blood  ;  finally,  the  vent- 
ricles relax  also,  and  so  the  cycle  ia  completed.  We 
have  thus  in  rapid  succession  auricular  systole,  vent- 
ricular systole,  and  ventricular  diastole  ;  the  auricular 
diastole  commencing  during  ventricular  systole,  and 
ventricular  diastole  continuing  through  auricular 
systole. 

The  beginning  of  ventricular  systole  is  marked 
by  the  closure  of  the  mitral  and  tricuspid  valves, 
which  had  remained  open  during  the  systole  of  the 
auricles,  and  by  the  occurrence  of  the  apex  beat ;  the 
beginning  of  ventricular  diastole  is  marked  by  the 
closure  of  the  aortic  and  pulmonary  valves,  which 
remain  closed  until  the  beginning  of  the  following 
ventricular  systole.  The  pulse  in  the  carotid  occurs  a 
short  time  after  the  commencement  of  A^entricular 
systole  ;  in  the  radial  artery  it  is  decidedly  later  in 
its  appearance,  and  therefore  the  radial  pulse  must 
never  be  taken  as  an  index  to  the  commencement 
of  ventricular  systole.  The  carotid  pulse  is  less 
fallacious  than  the  radial,  but,  as  an  index  to  the 
commencement  of  systole,  preference  should  be  given 
to  the  apex  beat  whenever  it  is  available. 

Various  authors  have  constructed  diagrams  to 
represent  the  sequence  of  events  in  a  cardiac  cycle. 


AUSCULTATIOX. 


^35 


TliH  following  one  (Fig.  30)  may  be  taken  as  represent- 
ing these  in  an  ordinary  case,  though  the  relative  dura- 
tion of  the  successive  events  will  be  found  in  practice 
to  vary  within  fairly  wide  limits.  The  most  important 
variation  is  that  when  the  heart  acts  with  unusual 
rapidity  the    duration    of  diastole    is  curtailed   to  a 


CAROTfD 
FULSE 


Fig. 


Ra  OfAL    PuL.  5E 

30. — CanJiac  evcle. 


greater  degree  than  that  of  systole,  and  hence  a 
shorter  interval  elapses  between  the  time  of  closure  of 
the  semilunar  valves  and  the  commencement  of  vent- 
ricular systole  than  one  would  infer  from  an  examina- 
tion of  the  diagram.  For  some  purposes  it  is  found 
more  convenient  to  unroll  the  above  diagram,  so 
that  the  sequence  is  represented  along  a  straight  line 
instead  of  round  a  circle.  When  this  is  done  the 
scheme  takes  the  foi*m  represented  in  Fig.  31. 

In  addition  to  a  knowledge  of  the  cardiac  cycle. 


136 


Circulatory  Svste.u. 


auscultation  presupposes  acquaintance  with  the  situa- 
tion of  the  valves  of  the  heart  and  of  the  course  of 
the  principal  arteries,  as  well  as  of  the  areas  where 
sounds  produced  at  the  valves  are  best  heard.  For 
full  particulars  the  student  must  consult  works  on 
regional  anatomy.  The  following  summary  merely 
recapitulates  the  most  important  facts. 

The  piilmoiiary  valve  lies  horizontally  at  the 
level  of  the  upper  border  of  the  third  left  costal 
cartilage  ;  the  right  half  of  the  valve  lies  under  cover 


u 


12  12  1 

Fig  31. 
1,  First  sound;  2,  second  sounil. 

of  the  sternum,  the  remainder  passes  outwards  behind 
the  costal  cartilage  (Fig.  32). 

The  aortic  valve  lies  farther  from  the  surface, 
and  at  a  slightly  lower  level.  Its  situation  may 
be  indicated  on  the  front  of  the  chest  by  a  line  drawn 
horizontally  across  the  left  half  of  the  sternum  on  the 
level  of  the  lower  border  of  the  third  costal  cartilage. 

The  mitral  valve  lies  slightly  obliquely  behind 
the  inner  end  of  the  fourth  left  costal  cartilage  and 
adjoining  part  of  the  sternum.  The  trieiispid 
valve  is  placed  much  more  obliquely ;  its  upper  end 
is  opposite  the  fourth  interspace,  and  its  lower  near 
the  lower  border  of  the  fifth  right  costosternal 
articulation.  It  marks  the  line  of  junction  between 
the  right  auricle  and  right  ventricle. 

The  piiliiioiiary  artery  is  situated  at  the 
inner  edge  of  the  second  left  interspace,  and  behind 
the  adjacent  part  of  the  sternum.  At  the  lower 
border  of  the  second  cartilage  it  divides  into  its 
branches  to  the  right  and  left  lungs. 

The  ductus  arteriosus  passes  upwards  from 
the  left  branch  to  join  the  aorta. 


A  USCUL  TA  TION. 


137 


The  siortsi  arises  behind  and  slightly  lower  down 
than  the  pulmonary  artery,  and,  passing  upwards  and 
to  the  right,  approaches  the  surface  of  the  chest  most 
closely  at  the  inner  end  of  the  second  right  costal 
cartilage,  arching  backwards  and  to  the  left  from  that 


Fi. 


-Positiuu  ul'  the  cardiac  valves  ;uiil  auscultatorv  ureas. 


point.  The  iiiiiomiiiate  artery  passes  in  a  direc- 
tion represented  by  a  line  drawn  from  the  middle  of 
the  manubrium  to  the  right  sternoclavicular  junction. 
A  stethoscope  i)laced  over  the  valves  of  the  heart 
would  fail  to  distinguish  at  which  of  them  a  given 
sound  takes  origin,  because  they  lie  so  near  each 
other  that  the  sounds  from  all  of  them  would  reach 
its  chest  piece.  Besides,  in  the  case  of  the  valves 
that  lie  more  deeply  the  sounds  would  have  to  pass 


138  Circulatory  System. 

through  the  chambers  of  the  heart  which  are  situated 
between  them  and  the  surface,  and  thereby  their 
clearness  would  be  impaired.  To  avoid  these  incon- 
veniences, the  sounds  produced  by  each  valve  are 
listened  for  over  that  part  of  the  chest  where  the 
cavity  in  which  the  valve  lies,  most  closely  approaches 
the  surface,  and  is  most  remote  from  the  other  cavities 
of  the  heart. 

Hence  one  listens  to  the  mitral  valve  at  the 
cardiac  apex,  to  the  tricuspid  at  the  lower  end  of  the 
sternum,  to  the  aortic  over  the  aorta  at  the  second 
right  costal  cartilage,  and  to  the  pulmonary  over  the 
artery  in  the  second  left  intercostal  space.  It  is 
practically  found  that  in  these  regions  the  sounds  of 
the  respective  valves  are  heard  with  a  maximum  of 
loudness  and  distinctness.  They  are  therefore  called 
the  mitral,  tricuspid,  aortic,  and  ptiliiioBiary 
areas,  although  they  do  not  lie  immediately  over  the 
valves  from  which  they  derive  their  names.  Auscul 
tation  should  be  performed  systematically  over  these 
areas.  In  ordinary  cases  the  student  may  begin  with 
the  mitral  area,  making  certain  of  the  time  at  which 
the  sounds  that  he  hears  occur  in  the  cardiac  cycle  by 
feeling  the  apex  beat  whilst  he  listens.  He  may  then 
pass  to  the  tricuspid  area,  thereafter  to  the  aortic,  and 
lastly  to  the  pulmonary.  When  necessary,  ausculta- 
tion may  also  be  performed  along  a  diagonal  line 
joining  the  mitral  and  aortic  areas.  This  is  often  of 
service,  as,  for  instance,  when  a  mitral  systolic 
murmur  is  associated  with  an  aortic  one. 

Ill  health  two  sounds  are  heard  over  each 
of  these  areas,  the  first  corresponding  with  the 
beginning  of  ventricular  systole,  the  second  with  the 
commencement  of  ventricular  diastole.  The  first 
sound  depends,  from  the  clinical  standpoint,  chiefly 
on  the  closure  of  the  mitral  and  tricuspid  valves,  and 
to  a  lesser  degree  on  the  muscle  tone  of  ventricular 


A  use  ill.  TA  TION. 


139 


contraction,  on  which,  however,  its  duration  depends, 
and  on  other  subsidiary  causes.  The  second  sound  is 
due  to  the  closure  of  the  aortic  and  pulmonary  valves, 
and  also,  but  very  subordinately,  to  tension  of  the 
vessel  walls.  This  sound  is  sharper  and  shorter  than 
the  first,  which  continues  through  an  a})preciable 
period  of  systole,  but  not  until  its  termination.  At 
and  to  the  left  of  the  apex,  only  the  aortic  element 
of  the  second  sound  is  audible.  The  observer  must 
remember  that  it  is  always  important  to  note  the 
character  of  both  the  first  and  second  sounds  in  each 
of  the  areas.  In  disease  the  following  deviations 
from  the  normal  may  occur  : — 

1.  The  sounds  may  have  a  different  intensity, 
both  absolutely  and  relatively  to  each  other,  from 
that  which  they  possess  in  health.  In  estimating  this, 
allowance  must  be  made  for  the  thickness  of  the  chest 
wall  and  the  volume  of  the  lungs. 

2.  The  sounds  m^^y  Vje  doubled,  or  their  rhythm 
altered. 

3.  Adventitious  sounds  may  be  heard;  either 
replacing  or  occurring  along  with  the  heart  sounds. 

1.  {a)  The  fii'!$t  i^oiiiid  may  l>e  weaker  than 
usual.  Decided  shortening  or  weakness  of  the  first 
sound,  still  more  its  disappearance,  indicates  cardiac 
failure.  In  acute  febrile  disease  this  change  may 
occur  rapidly,  and  should  always  be  looked  for;  the 
left  side  of  the  heart  generally  yields  first. 

{h)  The  first  sound  may  be  louder  than 
usual.  It  is  then  said  to  be  aceeutuated.  In 
simple  dilatation  the  sound  is  often  slightly  accentu- 
ated and  very  clear,  sharp,  and  short,  as  a  large 
volume  of  blood  is  projected  against  the  valve  cur- 
tains, and  the  sound  easily  penetrates  the  thin  ven- 
tricular wall  to  the  observer's  ear.  In  hyiyertrophy 
the  sound  is  accentuated  but  dull,  prolonged,  and 
thudding,  as  the  vibrations  produced  by  the  unusually 


140  Circulatory  System. 

forcible  closure  of  the  valve  have  to  pass  through  the 
thickened  heart  walls,  and  the  muscular  element  of 
the  sound  is  specially  prominent. 

(c)   If  the  {Second  sound  is  more  distinct  in 

the  mitral  or  tricuspid  areas  than  the  first,  we  have 
either  to  do  with  a  weakened  first  sound  or  an  accentu- 
ated second  ;  whilst  if  the  first  sound  is  louder  than 
the  second  in  the  aortic  and  pulmonary  areas,  the 
first  sound  is  accentuated. 

{d)  The  relative  loudness  of  the  second 
sound  in  the  aortic  and  pulmonary  areas  varies  some- 
what, and  is  a  good  deal  influenced  by  the  patient's 
age.  The  pulmonary  sound  is  rather  more  accentu- 
ated than  the  aortic  in  youth ;  in  old  age  the  reverse 
is  the  case  ^  when  the  subject  is  in  good  health. 

Accentuation  of  the  second  sound  means 
that  the  valve  where  the  accentuated  sound  is  pro- 
duced is  closed  with  unusual  force.  The  force  of 
closure  depends  on  the  momentum  of  the  column  of 
blood  that  effects  it,  and  the  momentum  depends 
equally  on  the  mass  of  moving  blood  and  on  the 
velocity  of  its  recoil  against  the  valve.  In  the  aorta 
the  mass  of  blood  is  increased  when  the  vessel  is 
dilated  near  its  origin  ;  the  velocity  of  recoil  when, 
in  consequence  of  contracted  arterioles  or  other 
obstruction  to  the  outflow  of  blood,  the  arterial  blood 
pressure  is  increased.  When  the  aortic  accentuation 
is  due  to  the  former  cause,  the  sound  often  assumes 
a  peculiar  resonance  suggestive  of  the  echo  produced 
when  a  cork  is  drawn  from  an  empty  bottle.  Over 
the  pulmonary  artery  an  accentuation  of  the  second 
sound  generally  indicates  increased  blood-pressure  in 
the  pulmonary  circulation,  due  either  to  disease  of 
the  lungs  or  of  the  left  side  of  tlie  heart.  In 
jjneumopericardium  the  sounds  are  singularly  clear 
and  resonant,  in  pericardial  effusion  they  are  faint 
*  Cf.  Beneke  :  "Die  Altersdisposition, "  plate  1. 


A  USCUL  TA  TION.  1 4 1 

and  muffled,  hi  'pnPAimothorax  tliey  arc  in  many 
instances  accentuated  and  clear,  wliilst  when  there 
are  cavities  in  the  lung  near  one  of  the  valve  areas, 
the  sound  arising  in  that  area  may  be  reinforced  by 
the  cavity  acting  as  a  resonator. 

2.  Under  certain  conditions  the  first  or  the  second 
sounds  may  be  doubled.  Various  explanations  have 
been  offered  to  account  for  the  reduplication.  The 
simplest  is  that  which  assumes  that  when  such  a 
doubling  occurs,  the  valves,  either  cuspid  or  semi- 
lunar as  the  case  may  be,  close  sooner  on  one  side  of 
the  heart  than  on  the  other  ;  the  reason  being  in  the 
case  of  the  mitral  and  tricuspid,  asynchronism  of 
systole  of  the  respective  ventricles,  and  in  the  case  of 
the  aortic  and  pulmonary  valves  some  variation  of 
the  normal  relations  of  blood  pressure  in  the  aorta 
and  pulmonary  arteries,  since  an  increase  in  pressure 
will  accelerate  the  closure  of  the  valve  which  is 
subjected  to  it.  This  view  is  probably  correct  in 
some  but  not  in  all  cases.  Clinically,  reduplication 
of  the  first  sound  occurs  under  very  various  con- 
ditions, the  most  important  variety  being  known  as 
the  "bruit  de  galop,^'  where  the  rhythm  at  the 
apex  shows  the  accent  on  the  second  element  of  the 
triplet  ^  —  ^.  In  some  cases  the  appearance  of  this 
"  bruit  de  galop  "  is  of  very  unfavourable  import."^ 

Reduplication  of  the  second  sound  in- 
dicates, in  a  large  proportion  of  the  instances  in 
which  it  is  heard,  an  increase  of  pressure  in  the  pul- 
monary circulation.  It  occurs,  therefore,  in  certain 
lung  diseases  and  in  diseases  of  the  left  side  of  the 
heart,  being  very  characteristic  of  mitral  stenosis,  in 
which  disease  it  is  heard  in  a  large  proportion  of  the 
cases.  It  should^  however,  be  mentioned  that  many 
observers   do  not  consider  that   the   reduplication  in 

*  Of.  Fraentzel,     "  Yorlesungen    uber    die    Kiankheiten    des 
Herzens,'"  Part  I.,  p,  56. 


142  Circulatory  System. 

mitral  stenosis  is  due  to  early  closure  of  the  pulmonary 
valves."^ 

Alterations  in  the  rhytliiii  of  the  sounds  deserve 
attention.!  The  usual  rhythm  is  that  of  triple  time 
in  music,  with  the  accent  on  the  first  beat  in  the 
mitral  and  tricuspid  areas,  and  on  the  second  in  the 
aortic  and  pulmonary,  whilst  the  third  beat  is  silent. 
This  is  slightly  modified  by  the  fact  that  a  quickly- 
acting  heart  gains  time  chiefly  in  the  period  of  ven- 
tricular diastole,  but  the  relation  of  the  sounds  is  less 
modified  by  this  than  the  phases  of  the  cycle  are. 
When,  however,  the  vitality  of  the  heart  has  been 
seriously  impaired  by  long- continued  high  blood 
tension,  such  as  is  seen  in  chronic  nephritis,  and 
especially  if  fever  or  some  such  cause  assists  in  weaken- 
ing the  myocardium,  the  sounds  become  almost 
equidistant,  the  period  of  ventricular  systole  being 
unduly  lengthened. 

This  deliberate  ^J«7if/'^tZ?t7>i-Z^A;e  sequence  of  the 
sounds  should  always  be  regarded  with  considerable 
anxiety,  as  it  points — unless,  indeed,  the  patient  is 
being  overdosed  with  digitalis — to  serious  involve- 
ment of  the  cardiac  muscle. 

Exactly  the  opposite  effect  is  produced  on  the 
rhythm  when  systole  is  rapidly  accomplished,  or  when, 
from  great  weakness,  the  ventricle  fails  to  efiect  a 
complete  emptying  of  itself,  and  the  systole  becomes 
abortive. 

3.  Adventitious  sounds  are  sometimes  endo- 
cardial in  origin,  at  others  exocardial.  Those  which 
are  endocardial  are  called  miirmurs.  They  are  due 
to  disease  either  of,  or  close  to,  the  valve  where  they 
occur,  when  they  are  often  known  as  organic ;  or  to 
some  alteration  in  the  state  of  the  blood,  which,  by 

*  Vide  infra,  p.  147. 

t  For  fuller  information,  consult  Broadbent's  "The  Pulse," 
p.  63. 


A  use  UL  TA  TION.  1 43 

.-ilU'ctiiig  its  viscosity  on  the  one  hand  and  the 
nutrition  of  the  tissues  of  tlie  heart  and  vessels  on 
tlie  other,  produces  the  conditions  necessary  for  the 
de\elopnient  of  a  murmur. 

The  physical  explanation  of  niurninrs  is 
by  no  means  simple,  the  following  are  some  of  the 
factors  concerned  in  their  production  : — 

1.  The  viscosity  of  the  blood  ; 

2.  The  velocity  of  the  blood-stream  ; 

3.  The  passage  of  the   stream  from  a  narrower 
into  a  wider  channel. 

The  third  condition  is  equally  well  produced  when 
a  narrowed  oritice  leads  to  a  normal  cavity  beyond  it, 
or  when  a  normal  orifice  opens  into  a  dilated  cavity. 

Endocardial  nnirmiirs  always  have  a  definite 
relatio7i  to  the  events  occurriny  in  the  course  of  tlie 
cardiac  cycle,  their  time  and  import  varying  with  their 
point  of  origin. 

In  the  so-called  "organic"  cases,  where  the  valves 
or  their  surroundings  are  iuiplicated,  a  murmur  may 
either  result  from  obstruction  to  the  onward  flow  of 
the  blood,  or  from  leakage  backwards  through  a 
closed  but  incompetent  valve.  The  former  are  known 
as  obstructive  murmurs,  the  latter  as  regurgitant. 
In  examining  a  murmur  the  following  points  must  be 
noted  : — 

1.  Its  time  of  occurrence  ; 

2.  Its  point  of  maximum  intensity ; 

3.  Its  direction  of  selective  propagation  beyond 
the  ]n-a?cordial  area ; 

4.  Its  character. 

The  time  of  its  occurrence  is  noted  with 
reference  to  the  sounds  of  the  heart,  and  these  by 
comparison  with  the  time  of  occurrence  of  the  apex 
beat. 

The  maximum  loudness  of  a  murmur 
which  has  been  produced  at  a   given  valve  usually 


144  ClRCULATORV  SVSTEM. 

occurs  at  the  point  where  the  valve  sound  would  be 
best  heard  in  health.  To  this  rule,  however,  there 
are  some  exceptions. 

Experience  shows  that  valvular  murmurs  are  not 
equally  well  heard  at  all  points  of  the  chest  wall  which 
are  equidistant  from  the  point  of  their  greatest  inten- 
sity, but  that  each  is  much  more  distinctly  audible  at 
a  distance  in  some  directions  than  in  others  ;  this  fact 
is  expressed  by  saying  that  such  murmurs  have 
directions  of  selective  propag^ation.^ 

The  character  of  the  murmur  also  helps  to  de- 
cide a  doubtful  case.  Obstructive  murmurs  are  apt 
to  be  rough  ;  regurgitant  to  be  soft  and  blowing. 

The  pitch  and  general  quality  of  murmurs  vary 
greatly  ;  some  have  quite  a  distinct  musical  character, 
others  are  harsh  and  sawing.  The  loudness  of  a 
murmur  has  no  relation  to  the  amount  of  damage 
which  causes  it.  A  very  loud  murmur  is  often  far 
less  serious  than  one  so  soft  as  to  be  nearly  inaudible. 

Murmurs  due  to  disease  of  extra-uterine  origin  are 
very  much  oftener  found  to  proceed  from  the  valves 
of  the  left  side  of  the  heart  than  from  those  of  the 
right,  and  in  adult  life  murmurs  at  the  tricuspid  and 
pulmonary  areas,  due  to  morbid  processes  arising  in 
these  valves,  are  rare.  The  following  is  a  short  epitome 
of  the  chief  murmurs  which  may  be  heard  at  the 
various  valves :  the  diagrams  illustrate  the  position  of 
the  more  common  ones  in  the  cardiac  cycle. 

I. — mitral  murmurs.  These  may  be  either 
obstructive  or  regurgitant  (Fig.  33). 

*  The  complete  explanation  of  the  selective  propagation  of 
many  murmurs  is  still  unknown.  In  most  cases,  however,  the 
following  factors  greatly  influence  the  direction  in  which  the 
murmur  is  conducted  : — (1)  The  varying  conductivity  of  the 
different  structures  in  the  chest  wall,  and  between  the  chest  wall 
and  the  heart ;  (2)  the  direction  of  the  vibrating  blood-stream  ; 
(3)  the  position  of  the  chamber  of  the  heart  or  of  the  vessel 
in  which  the  valve  lies. 


Auscultation. 


145 


{a)  Obiiitriirtive  murmurs  occur  during  ventri- 
cular diastole,  and  are  invariably  of  organic  origin. 
They  sometimes  follow  immediately  on  the  second 
sound  when  they  are  known  simply  as  "  diastolic.''^ 
At  other  times  the  murmur  is  separated  from  the 
second  sound  by  a  brief  interval,  but  terminates  before 
the  occurrence  of  the  first  sound,  it  is  then  called  '•'■  mid- 
diastolic " ;  in  yet  other  instances  the   murmur  only 


Mitral. 


IIIJIIIHIIlii, 


Syst.ilic 
O'cguroitant) 


Presystolic 
(obstructive) 


Diastolic  luitrul 


Diastolic  and  iiresystolic 
mitral 


Presystolic  and  systolic 
(double) 


Rare  forms  of  mitral 
obstructive  murmurs 


Fig.  33. 

begins  with  the  advent  of  auricular  contraction,  when 
it  is  designated  an  '■'' auriculo-systolic,''^  or,  more  often,  a 
"  presystolic  "  murmur.  In  each  case  the  murmur  is 
due  to  the  onward  rush  of  the  blood  through  the  de- 
formed or  narrowed  mitral  valve  into  the  wider  cavity 
of  the  left  ventricle.  During  the  earlier  part  of 
diastole  this  is  effected  by  the  aspiration  of  the  relax- 
ing ventricle,  which  is  ordinarily  strongest  near  the 
beginning  of  diastole — at  the  end  of  the  period  the  con- 
tracting auricle  is  the  main  agent  in  producing  the  flow. 
Sometimes  an  early  diastolic  murmur  is  followed  by  a 
moment  of  silence,  w^hich  is  then  succeeded  by  a  pre- 
systolic murmur.*     Best  heard  at  the  apex,  or  some- 

*  The  term  "  post-diastolic  "  as  applied  to  certain  of  these  mur- 
murs is  very  misleading.  They  are  all  diastolic  in  time,  though, 
as  has  been  stated,  some  are  separated  from  the  second  sound  by 
a  pause. 

K 


146 


ClR CULATORY   S YS TEM. 


times  rather  nearer  the  sternum,  they  have  no  direc- 
tion of  selective  propagation  ;  they  are  harsh  and  rough 
in  character,  more  particularly  when  of  the  presystolic 
variety,    and  very  often  are  associated  with  a  distinct 


Fig.  34. — Presystolic  initial  inurnmr. 


thrill.  In  the  majority  of  cases  the  second  sound  is 
reduplicated  so  that  the  murmur  and  accompanying 
sounds  may  be  phonetically  represented  by  "rriip  ti-ti" ; 
or,  where  the  heart's  action  is  rapid  and  the  murmur 
occupies  a  considerable  portion  of  the  diastolic  [)eriod, 
by  "ti-ti  rriip."  Occasionally  the  presystolic  murmur 
is  accompanied  by  a  mitral  obstructive  murmur  oc- 
curring at  the  beginning  of  diastole,  when  the  pho- 
netic representation  would  become  ' '  7-rup  ti  tiff  rriip  ti 
tiff"  or,  if  the  murmur  occur  a  shade  later  in  diastole, 
by  "rr up  titi  iff,  rrup  titi  iff." 


Auscultation. 


M7 


The  exact  significance  of  the  reduplication  of  the 
second  soiin  din  mitral  obstruction  is  a  matter  of  dubiety. 
At  present  many  observers  deny  that  the  second  ele- 
ment of  the  reduplication  is  produced  at  the  semilunar 


Fig.  35. — Mitral  systolic  iminuur— proiiagatiou  in  front. 

valves,  and  the  fact  that  it  is  better  heard  at  the  apex 
than  at  the  base  supports  their  contention.  No  other 
very  satisfactory  explanation  is,  however,  available  to 
account  for  the  sound,  which  some  consider  to  be  a 
short  murmur  (Fig.  34). 

{b)  Regurgitant  iiiuriniirs  occur  during  ven- 
tricular systole  and  may  be  either  organic,  or  simply 
due  to  dilatation.  They  begin  with  the  apex  beat 
and  replace  more  or  less  completely  the  first  sound 
in  the  mitral  area.  Their  point  of  maximum  in- 
tensity is  at  the  apex,  their  direction    of   selective 


148 


CiRCULA  TOR y  System. 


propagation  is  outward  towards  the  axilla  and  angle 
of  the  left  scapula,  and  they  are  generally  soft  and 
blowing  in  character.  Slight  mitral  systolic  murmurs, 
especially  those  due  to  dilatation  of  the  ventricle  and 
mitral  orifice  and  not  to  disease  of  the  valve  curtains, 


vgis/ 


Fig.  36.  —Mitral  systolic  muiiuur — propagation  behind, 

frequently  lack  any  selective  propagation  backwards. 
It  is  possible  that  some  basal  h^emic  murmurs  may  be 
due  to  mitral  regurgitation  when  the  left  ventricle 
is  dilated  {see  p.  153)  (Figs.  35,  36). 

II. — Aortic  iiiuriiiiirs  (Fig.  37). 

{a)  Obstructive  iiiuriiiiirs  occur  during  ven- 
tricular systole,  they  are  due  either  to  obstruction  of 
the  ostium  aortse  from  valve  disease  or  to  aortic  dila- 
tation beyond  a  normally-sized  ostium.  They  are 
rough  in  character  ;  have  their  area  of  greatest  loud- 


Auscultation. 


149 


ness  at  the  second  riofht  costal  cartilacje  near  the 
sternum  ;  are  propagated  with  the  blood-stream  into 
the  arteries  ;  and  may,  in  most  instances,  be  readily 
heard  over  the  carotids — sometimes  at  a  much  greater 
distance  (Fig.  38). 

(h)  Rrgiirgitaiit  miiriniir^  occur  during  ven- 
tricular diastole  ;  they  begin  with  the  closure  of  the 
semilunar  valves,  and   replace  in  part  or  completely 


[I 


(iilislriirtive) 


A 

LORTir. 

iLn 

J 

,1k 

lllii,. 

I)i 
(reij 

astolic 
urgit(ivt) 

Sypri 

lie  riiid  dhi^rulir 
((toiihlf) 

Fig.  T, 


the  normal  second  sound  in  the  affected  region.  They 
are  sometimes  heard  best  in  the  aortic  ai'ea;  not  infre- 
quently, however,  they  are  as  distinctly  audible  over 
the  left  half  of  the  sternum,  at  the  level  of  the  third 
rib  and  interspace.  Their  direction  of  selective  pro- 
pagation is  towards  the  lower  end  of  the  sternum, 
though  occasionally  they  are  almost  equally  well  heard 
near  the  apex  ;  their  character  is  less  harsh  than  that 
of  systolic  aortic  murmurs.  Their  intensity  is  greatest 
at  first,  and  gradually  diminishes  during  the  diastolic 
period.  Marked  regurgitation  leads  to  auscultatory 
phenomena  in  the  arteries  (see  p.  155)  (Fig.  39). 

In  many  instances  one  finds  that  a  double 
iniiriiiur  is  present  at  the  aortic  orifice,  the  systolic 
element  of  which  is  not  caused  by  real  stenosis  of  the 
ostium,  but  l»y  roughening  and  deformation  of  the 
valve  segments,  the  diastolic  murmur  being  due  to  the 
backward  leakage  through  the  misshapen  cusps.  This 
double  murmur  often  possesses  a  very  distinctive 
"  sawing  "  character. 

III. — Tricuspid  inuruiurs  are  comparatively 
rare. 


150  Circulatory  System. 

(a)  Obstructive  iniiriiiiii's  resemble  those  of 
the  mitral  valve,  but  have  their  maximum  inten- 
sity at  the  lower  end  of  the  sternum.  They  have 
no  selective  propagation. 

(h)    Reg-iirg^itaiit    miiriiiiirs    have    a    similar 


Fig.  38. — Aortic  systolic  murmur. 

character  to  mitral  regurgitant  murmui'S,  are  best 
heard  in  the  tricuspid  area,  and  are  associated  with 
the  venous  pulse,  q.v.  (p.  175).  The}^  are  usually  a 
sequel  to  disease  of  the  left  side  of  the  heart,  after 
compensation  has  failed. 

IV. — Pulmonary  uiiiruiurs  (Fig.  40)  are  best 
heard  in  the  pulmonary  area,  have  no  direction  of 
selective  propagation,  are  usually  systolic,  though 
occasionally  they  are  well  heard  as  higli  as  the  first 
rib,  and  are  rarely  due  in  extra-uterine  life  to 
disease  of  the  valve,  but  are  most  often  caused  by 


A  use  UL  TA  TION.  I  5  I 

dilatation  of  the  artery  be3'^ond  tlie  valve  ring.  They 
are  very  well  heard  in  many  cases  of  exophthalmic 
goitre. ■'^  A  diastolic  pulmonary  murmur  is  excessively 
rare. 

In  a  large  number  of   cases    more  tliaii   one 


Fig.  39. — Aortic  diastolic  murmur. 

iiiuriniir  is  present  during  the  cardiac  cycle.  When 
they  occur  at  different  epochs,  it  is  easy  to  study  each 
separately  ;  when  two  or  more  occur  together,  each 
will  be  found  to  possess  its  own  position  of  maximum 
loudness,  its  characteristic  direction  of  selective  pro- 
pagation, and  its  ])eculiar  quality  of  sound  (Fig.  41). 
Each  lesion,  moreover,  will  produce  more  or  less  definite 
effects  on  the  general  circulation,  and  by  obser^'ing 
these  by  the  other  methods  at  our  disposal,  a  diagnosis 

*  In  these  cases  there  is  often  an  aortic  svstolic  murmur  also. 


152 


ClR C UL A  TORY   SyS TEM. 


can  usually  be  arrived  at.  It  must  be  recollected  that 
during  the  last  few  days  of  life,  when  the  diseased 
heart  is  acting  feebly,  serious  lesions  are  often  un- 
accompanied   by    any   murmur,    the    force     of     the 


Fig.  40. — Pulmonary  systolic  murmur. 


blood-stream    being     too     weak     to     produce    any 
vibration. 

A  patent  forainen  ovale  may  give  rise  to 
a  murmur  at  the  base  of  the  heart,  dependent  on 
difference  of  pressure  in  the  right  and  left  auricle  ;  a 
murmur  usually  rather  harsh  in  character,  systolic  in 
time,  and  with  its  maximum  intensity  at  the  level  of 
the  second  left  costal  cartilage  and  first  interspace,  a 
short  distance  outwards  from  the  sternum,  is  some- 
times caused  by  the  ductus  arteriosus  remaining 
unclosed. 


Auscultation. 


153 


H^MIC    BRUITS. 

Ill  aiiseiuia  several  murmurs  are  frequently 
heard  over  the  heart  and  vessels.  One,  which  is  of 
specially  common  occurrence,  is  audible  in  the  second 


Fig.  41. — Combined  aortic  and  mitral  systolic  murmurs. 


left  intercostal  space  over  or  just  external  to  the  pul- 
monary area.  Various  theories  have  been  advanced 
to  account  for  it.     The  chief  of  these  are — 

1.  Naiiiiyii's  theory,  where  it  is  held  that  the 
sound  is  due  to  reguro-itation  th rough  the  mitral  valve 
into  the  left  auricle,  and  that  it  reaches  the  ear  by 
way  of  the  auricular  appendix,  which  for  various 
reasons — includino-  the  fact  that  tlie  anterior  border 
of  the  left  lung  is  often  rather  retracted  in  anaemia — 
approaches  the  chest  wall  more  closely  than  under 
other  conditions.      Naunyn  and  others  have  pointed 


154  Circulatory  System. 

out  that  the  murmur  attains  its  maximum  intensity 
not  over  the  puhnonary  artery,  as  is  found  in  un- 
doubted cases  of  puhnonary  systoHc  murmurs,  but 
farther  to  the  left ;  and  the  writer's  observations 
confirm  this  statement  in  a  preponderating  majority 
of  cases. 

2.  Russell's  theory. — This  theory  assumes  that 
the  left  auricle  is  dilated  and  tilled  with  blood  at  un- 
usually high  pressure,  and  that  it  therefore  presses 
sufficiently  firmly  against  the  pulmonary  artery  to 
produce  a  constriction.  The  hypothesis  is  unsup- 
ported by  any  cogent  facts,  and  is  inconsistent  with 
a  sound  view  of  the  mechanics  of  the  circulation. 

3.  Many  writers  regard  the  murmur  as  clue  to 
slig^lit  dilatation  of  the  pulmonary  artery  be- 
yond the  valve  ring,  and  to  a  less  viscous  condition 
of  the  blood,  which  would  accentuate  the  vibrations 
set  up  by  such  a  dilatation. 

4.  Sansom-^  holds  that  the  vibrations  which 
cause  the  murmur  arise  in  the  conus  arteriosus,  and 
perhaps  also  in  the  semilunar  valves  themselves,  and 
are  due  to  a  fibrillary  tremor  of  the  over-strained 
muscular  fibres  which  are  found  in  these  regions. 

The  first  and  third  of  the  above  theories  have 
at  present  the  greatest  number  of  supporters. 

Hsemic  murmurs  are  also  heard  at  times  in  the 
mitral,  and  much  less  frequently  in  the  tricuspid  and 
aortic  areas,  the  last  being  particularly  uncommon. 
In  all  cases  such  murmurs  are  systolic  in  time. 

A  continuous  humming  sound  is  often  audible 
over  the  veins  at  the  root  of  the  neck  in  chlorosis. 
It  is  known  as  the  hruit  de  diahle,  and  is  caused, 
in  part  at  least,  by  an  alteration  in  the  calibre  of  the 
internal  jugular  vein  as  it  passes  through  the  cervical 
fascia. 

In  order  to  hear  the  bruit  de  diable  clearly,  the 
*  "  Diagnosis  of  Diseases  of  the  Heart,"  p.  28-5. 


A  use  UL  TA  TION.  I  5  5 

stethoscope  must  he  held  very  lightly,  so  as  to  exert 
no  pressure,  over  the  clavicular  head  of  the  sterno- 
luastoid  muscle.  Not  seldom  one  may  also  hear  the 
sound  perfectl}'^  distiiictl}^  when  the  stethoscope  is 
placed  on  the  sternoclavicular  articulation,  by  wliich 
mano3u^'re  all  possibility  of  creating  a  factitious  bruit 
by  pressure  is  avoided. 

Uremic  murmurs  may  arise  in  the  larg'ei* 
arteries,  and  are  present  independently  of  the 
pressure  of  the  stethoscope,  and  it  seems  probable 
that  an  important,  if  not  the  chief,  factor  in  their 
production  is  a  disturbance  of  the  vasomotor 
mechanism  of  the  vessels."^ 

There  are,  moreover,  other  sounds  which  may 
become  audible  in  the  arteries,  and  which  are  the 
result  of  changes  in  the  pressure  of  the  blood-stream. 
The  most  notable  instance  of  this  is  found  where 
relaxed  arteries  are  so  rapidly  distended  by  a  large 
blood- wave  that  their  walls  are  thrown  into  vibration 
by  the  sudden  strain,  and  a  sound  is  produced  which 
corresponds  with  the  advent  of  the  pulse-wave.  In 
cases  of  aortic  regurgitation,  where  these  conditions 
are  most  fully  developed,  we  have  also  a  second  sound 
which  occurs  at  the  instant  when  the  pressure  once 
more  falls  off.  This  double  sound,  when  heard  in  the 
femoral,  is  very  characteristic  of  aortic  regurgitation. 
Pressure  produced  by  an  ill-applied  stethoscope  often 
converts  these  sounds  into  murmurs. 

A  murmur  in  the  subclavian  artery  as  it  crosses 
the  apex  of  the  lung  may  be  caused  iDy  pulmonary 
disease. 

When  there  is  an  aneiirysmal  dilatation  of 
the  aorta,  murmurs  may  or  may  not  be  present,  or 


■*  A  valuable  contribution  to  our  knowledge  of  the  pli3*sical 
causes  wliicli  lead  to  the  production  of  hgemic  bruits  is  to  be 
found  in  Thoma's  "  Textbook  of  General  Pathology "  (English 
edition,  vol.  i.,  p.  271). 


156  Circulatory  System. 

the  aortic  second  sound  may  be  accentuated  over  the 
sac  ;  but  no  definite  rule  holds  for  such  cases.  When 
an  aneurysm  opens  into  another  large  vessel — such, 
for  example,  as  the  superior  vena  cava — the  murmurs 
produced  may  be  very  loud,  and  are  heard  in  unusual 
situations. 

Exocardial  i§oiinci§  may  be  due  either  to  peri- 
cardial friction  or  to  a  localised  pleurisy  near  the 
heart. 

When  pericardial  friction  occurs  over  an  area 
uncovered  by  lung,  it  has  a  singulavl37"  superficial 
character,  and  thus  can  often  enough  be  readil}^ 
recognised. 

Unlike  the  murmurs  already  described,  pericardial 
friction  does  not  correspond  definitely  with  the  events 
of  the  cardiac  cycle.  It  is  generally  more  distinct  in 
systole  than  in  diastole,  but  tends  to  exhibit  a  to-and- 
f  ro  character,  the  first  element  occurring  during  systole 
and  the  second  during  diastole,  but  not  necessarily 
commencing  at  the  beginning  of  either  phase.  Some- 
times the  sound  occupies  the  latter  part  of  systole  and 
the  early  part  of  diastole  without  exhibiting  any  pause 
between  its  first  and  second  elements  ;  sometimes  it 
remains  audible  during  the  whole  of  the  cardiac  cycle. 
Further,  its  position  of  greatest  intensity  does  not 
correspond  with  any  of  the  areas  in  which  valvular 
murmurs  are  best  heard,  and  it  is  not  propagated  to  a 
distance,  but  remains  confined  within  narrow  limits. 
Its  position  may  be  observed  to  vary  from  day  to  day. 
As  a  rule,  it  appears  first  near  the  l)ase  of  the  heart 
on  the  left  side,  but  when  the  condition  has  become 
general,  it  is  best  heard  near  the  left  nipple,  and  is 
sometimes  associated  with  a  distant  thrill.  The  in- 
tensity is  often  considerably  modified  by  the  attitude 
of  the  patient.  When  the  inflammatory  process  in- 
volves the  auricle  as  well  as  the  ventricle,  the  to-and- 
fro  rub  may  be  replaced  by  a  triple  friction  sound. 


A  use  UL  TA  rioN.  157 

In  pericarditis,  the  heart's  action  is  apt  to  become 
tumultuous,  and  when  fluid  is  poured  out,  the  cardiac 
sounds  become  faint  and  distant. 

When  air  and  fluid  are  present  in  tlie  pericardial 
sac — an  event  of  very  rare  occurrence — a  cliiiriiiiis: 
or  "water- wheel"  sotiiid  can  be  heard  on  aus- 
cultation. 

To  distinguish  between  the  rub  of  pericarditis  and 
that  of  pleurisy  over  a  neighbouring  portion  of  lung, 
the  patient  should  be  instructed  to  hold  his  breath. 
Pericardial  friction  is  unchanged  by  this,  but  if  it  be 
of  pleural  origin,  it  will  either  be  much  reduced  in 
intensity  or  will  wholly  cease.  On  the  other  hand, 
deep  respiration  will  increase  the  pleural  sound,  but 
will  not  influence  the  pericardial. 

The  possible  co-existence  of  both  pleuritic  and 
pericardial  friction  must  not  be  overlooked. 

SECTION    VI.— THE   PULSE. 

The  examination  of  the  pulse  gives  us  direct 
information  regarding  two  things,  namely,  the  con- 
dition of  the  vessel  walls  and  the  amount  and 
variations  of  pressure  of  the  contained  blood.  By 
intelligent  observation  of  these  facts  we  can  obtain 
very  valuable  information  regarding  the  state  of  the 
heart  and  circulation,  as  w^ell  as  the  general  state  of 
the  patient. 

When  any  observation  is  to  be  made  on  the  pulse, 
the  patient  should  be  lying  on  his  back,  or  at  least 
sitting  ;  and,  except  for  special  purposes,  should  not 
have  been  making  any  eflfort  for  some  little  time 
previous  to  the  examination.  The  pulse  is  most 
readily  felt  when  the  patient's  forearm  is  pronated. 
In  cases  of  aortic  regurgitation  the  peculiar  character 
of  the  pulse  {vide  infra,  p.  170)  is  more  distinctly 
brought  out  when  the  patient's  arm  is  elevated. 

To  feel  the  pulse  place  three  fingers  of  the  right 


158  Circulatory  System. 

hand  on  tlie  patient's  radial  artery  at  the  wrist.  It 
is  immaterial  Avhether  the  observer's  index  finger  be 
nearest  the  elbow  or  the  hand  of  the  patient,  but  for 
beginners  it  is  best  to  select  the  same  position  in  all 
cases.  If  it  is  made  a  habit  to  examine  both  radials 
in  every  case,  errors  in  diagnosis,  such  as  failing  to 
detect  the  presence  of  aortic  aneurysm,  or  an  abnormal 
position  of  the  vessel,  w^ill  frequently  Idc  avoided. 

When  the  artery  is  beneath  the  finger,  the  follow- 
ing observatioiis  should  be  systematically  made  : — 

1.  Rate  of  pulse  ; 

2.  Rhythm  of  pulse ; 

3.  Equality  or  inequality  in  force  of  successive 
beats ; 

4.  The  condition  of  the  vessel  wall  and  the  size 
of  the  vessel ; 

5.  The  amount  of  movement  during  passage  of  a 
pulse-wave ; 

6.  The  blood  pressure  in  the  vessel  during  the 
beat  (maximum  pressure); 

7.  The  blood  pressure  between  the  beats  (mini- 
mum pressure); 

8.  The  general  character  of  the  pulse  as  regards 
rise,  maintenance,  and  fall  of  pressure,  and  the  pre- 
sence or  absence  of  secondary  waves. 

The  first  three  observations  depend  on  the  action 
of  the  heart,  the  fourth  on  the  vessel,  the  remainder 
on  both  heart  and  vessel,  the  latter  being  the 
dominant  factor  in  most  cases. 

The  rate  of  the  j)ulse  is  given  as  so  many  beats 
per  minute.  It  is  well  not  to  begin  counting  imme- 
diately the  finger  is  laid  on  the  pulse,  as  the  agitation 
of  the  patient  often  accelerates  it  at  first.  After 
waiting  till  it  resumes  its  normal  rate,  count  the  beats 
for  one  minute,  and  record  the  result.  The  beat  at 
which  the  observation  commences  should  not  be 
counted. 


Pulse.  159 

The  successive  be,!ts  of  the  pulse  may  recur  at 
equal  or  une(j[ual  intervals,  giving  a  reg'iilai'  or 
irre^ilar  liiytliiii.  In  the  latter  case,  the  beats 
may  occur  in  symmetrical  groups,  some  of  the  simpler 
of  which  have  received  special  names  :  thus  if  there  be 
two  beats  and  a  pause,  recurring  in  regular  sequence, 
we  obtain  the  pulsus  higeminus  (Fig.  4:2),  three  beats 
and  a  pause  give  the  pulsus  trifjeminus  (Fig.  43).  In 
other  cases  no  such    symmetry  occurs.     Besides  the 


Fig.  42. — Bigeminal  puLso.     (From  a  tracing  lent  hy  Dr.  Byrorn  Braniwell, 
"Student's  Guide  to  Examination  of  the  Pulse." 

varying  interval  that  may  occur  between  consecutive 
beats,  the  beats  themselves  may  be  unequal  in  force. 
Some  beats  may  be  weaker,  and  the  weaker  beats 
may  eventually  become  imperceptible — we  thus  arrive 
at  pulses  which  may  be  classed  under  the  previous 
heading  (irregular  pulses)  ;  this  is  especially  true  of 
the  symmetrical  types. 

The  fourth  observation  is  directed  to  ascertain  the 
state  of  the  vessel.  Two  points  should  be  noted  : 
first,  the  size  (calibre)  of  the  vessel ;  secondly,  the 
condition  of  its  walls. 

To  determine  the  calibre,  empty  the  vessel  of  blood 
by  firm  pressure,  and  endeavour  to  gauge  its  breadth 
in  the  flattened  state.  Should  this  be  impracticable, 
allow  the  blood  to  return  below  the  linger,  and  note 
the  size  of  the  cvlindrical  tube.     When  the  vessel  is 


i6o  Circulatory  System. 

contracted  the  calibre  is  siiial],  when  the  muscular 
coat  is  fully  relaxed  it  is  distinctly  larger.  Be  careful 
to  ascertain  that  the  radial  artery  is  really  under 
observation  ;  in  a  certain  proportion  of  cases  it  winds 
round  to  the  back  at  an  unusually  high  level,  whilst 
the  superficialis  volse  continues  to  run  in  the  usual 
site  of  the  larger  vessel.  One  may  thus  be  led  into 
error,  if  the  abnormal  distribution  is  not  recognised. 

To   discover    the    state    of  the   walls,   flatten    the 
vessel    and  cause  the  skin  of  the  patient's   wrist  to 


Fig.  43. — Trigeminal  pulse. 

slip  up  and  down  over  it.  In  health  the  vessel  wall 
can  rarely  be  felt  unless  the  arm  is  thin.  In  disease 
one  may  feel  general  or  local  thickening,  calcification, 
tortuosity,  or  irregular  dilatations.  These  changes 
must  be  discounted  when  an  attempt  is  made  to 
estimate  the  blood  pressure  in  the  vessel. 

Having  observed  the  state  of  the  vessel,  one  pro- 
ceeds to  apply  just  sufficient  pressure  to  flatten 
it  between  the  beats.  When  this  is  done  the 
increased  blood  pressure  that  is  present  during 
the  beat  will  cause  the  blood  vessel  to  resume  its 
cylindrical  shape  ;  and  further,  inasmuch  as  the  vessel 
wall  is  elastic,  will  stretch  it  until  the  internal  stress 
is  balanced  by  the  strained  wall. 

This  observation  enables  us  to  estimate  the  ampli- 
tude of  moveoieiit  of  the  vessel  wall  during  the 
passage  of  the  pulse-wave.  As  the  elastic  stretching 
of   the   vessel   is  never  great,  the  mo\'ement  chiefly 


Pulse.  i6i 

depends  on  the  resumption  by  the  flattened  artery  of 
its  cylindrical  shape,  and  the  amount  of  such  move- 
ment is  consequently  greater  the  more  dilated  the 
vessel  is.  The  force  of  the  heart's  action  also 
exercises  a  certain  influence  on  the  amount  of  move- 
ment, although  to  a  much  less  degiee  than  the  re- 
laxation or  contraction  of  the  coats  of  the  artery. 

This  proceeding  is  often  described  as  "  observing 
the  expatision  "  of  the  pulse. 

The  next  point  is  the  determination  of  the 
inaxiinuni  blood  pressure,  which,  of  course, 
occurs  during  the  beat.  In  this  case  three  fingers 
must  be  placed  on  the  artery,  so  that  it  may  be  com- 
pressed both  above  and  below  the  point  where  the 
pulse  is  being  felt. 

Place  the  finger  next  the  wrist  firmly  on  the 
vessel  to  prevent  any  pulse  from  the  ulnar  artery 
reaching  the  middle  finger  through  the  palmar  arch  ; 
let  the  middle  finger  rest  on  the  vessel  with  such 
pressure  as  will  render  the  pulse  most  distinct,  and 
then  gradually  compress  the  artery  above  this  point 
with  the  remaining  finger,  noting  the  pressure  em- 
ployed when  the  pulse  ceases  to  be  felt  by  the  middle 
finger.  This  pressure,  being  just  sufficient  to  pre- 
vent the  blood  from  lifting  the  finger  during  the 
beat,  corresponds  to  the  maximum  blood  pressure. 
Only  careful  practice  on  a  large  number  of  healthy 
and  diseased  pulses  will  enable  the  student  to  de- 
termine whether  in  a  given  case  the  requisite  pres- 
sure is  normal,  excessive,  or  diminished.* 

The  importance  of  cutting  off"  recurrent  pulsation 
through  the  palmar  arch  must  never  be  overlooked. 

*  A  new  form  of  sphygmometer  for  the  clinical  estimation 
of  blood  pressure  has  been  introduced  by  Leonard  Hill  and 
Barnard.  The  instrument  is  simple  in  construction,  easy  of 
application,  and  gives  results  which  are  found,  when  tested 
experimentally,  to  be  perfectly  accurate.  It  is  supplied,  along 
with  full  directions,  by  Hicks,  Hatton  Garden,  London,  E.C. 


1 62  Circulatory  System. 

It  is  most  likely  to  occur  in  cases  where,  owing 
to  vascular  dilatation,  the  blood  pressure  is  unusually 
low,  and  thus  if  neglected  would  lead  to  serious 
error,  as  the  middle  finger  would  continue  to  feel  the 
pulse  even  when  the  upper  finger  exerted  great 
pressure.  As  a  natural  consequence  the  observer 
would  greatly  over-estimate  the  maximum  blood 
pressui-e  in  the  vessel.  It  is  worth  noting  that  this 
recurrent  pulse  is  frequently  present  in  chlorosis. 

It  is  rather  more  difficult  to  estimate  the 
mininiiiiii  blood  pressure.  One  thing  may 
be  remembered — namely,  that  in  cases  where  the 
maximum  pressure  is  low  the  minimum  must  be  still 
lower ;  this  rule  must  not,  however,  be  extended 
into  an  assertion  that  a  high  maximum  will  necessarily 
involve  a  high  minimum  pressure. 

To  test  for  the  minimum  pressure,  one  may  attempt 
to  roll  the  vessel  from  side  to  side  under  the  fingers 
between  the  beats.  When  the  pressure  is  low,  one 
cannot  feel  the  vessel  at  all ;  if  it  is  high  it  may 
feel  as  hard  as  a  piece  of  whipcord.  Of  course,  one 
must  be  careful  not  to  be  misled  by  thickening  of  the 
wall  of  the  artery. 

Another  method  which  gives  good  results,  and 
which  may  be  more  easily  appreciated  by  many,  is 
to  feel  the  pulse  first  with  light,  then  with  moderate, 
and  finally  with  considerable  pressure  of  the  fingers  on 
the  artery.  A  pulse  of  low  tension  {i.e.  with  a  low 
minimum  pressure)  is  best  felt  in  the  first  case,  for 
the  light  pressure  is  sufficient  to  flatten  the  vessel 
between  the  beats,  whilst  it  allows  the  artery  to 
resume  its  cylindrical  shape  without  much  resistance 
during  the  beat,  and  is  thus  favourable  to  the 
development  of  the  greatest  possible  amplitude  of 
movement ;  whilst  on  the  contrary,  where  the  tension 
is  high  considerable  pressure  is  required  to  flatten 
the  vessel  between  the  beats.     But  one  obtains  the 


FULSE.  163 

greatest  amplitude  of  movement  precisely  when  the 
vessel  is  thus  flattened,  and  so  in  a  high-tension 
pulse  the  more  firmly  one  presses  the  more  forcible 
does  the  pulse  appear  to  grow. 

A  normal  pulse,  lying  as  it  does  between  these 
extremes,  is  best  developed  when  moderate  pressure 
is  applied. 

When  all  tliese  points  have  been  determined,  one 
should  conclude  by  studying  the  general  cha- 
racter of  the  piilse-beat.  This  is  divided  into 
three  periods :  first,  the  period  during  which  the 
blood  pressure  is  rising ;  secondly,  the  period  at 
which  the  blood  pressure  continues  near  its  maxi- 
mum ;  and  lastly,  the  period  during  which  the  blood 
pressure  once  more  falls  off. 

The  amount  of  movement  having  been  already 
observed,  one  tries  to  estimate  the  rapidity  of  the 
rise  of  pressure,  describing  the  rise  as  abrupt, 
rapid,  moderate,  or  slow.  In  cases  where  it  is  abrupt 
it  will  be  found  that  the  pulse  is  of  low  tension; 
where  it  is  slow  the  pulse  is  either  one  of  high 
tension  or  an  aneurysm  is  present.  The  latter  con- 
dition may  cause  the  rise  to  be  excessively  gradual. 
It  is  only  in  aneurysm  that  the  rise  of  pressure  may 
be  as  gradual  as  the  subsequent  fall. 

As  regards  the  period  at  which  the  pressure 
remains  near  its  maximum,  the  point  to  be  ob- 
served is  whether  the  pressure  is  well  sustained,  or 
whether,  on  the  other  hand,  it  has  no  sooner  attained 
its  hiijhest  value  than  it  begins  to  fall  off  again  with 
rapidity. 

In  the  third  period,  one  observes  whether  the 
fall  of  pressure  is  swift  or  gradual.  During  the 
fall,  instead  of  a  continuous  decrease,  there  may  be 
oscillations  of  pressure,  which,  in  marked  cases,  are 
quite  perceptible  to  the  finger  as  distinct  impacts 
foUowingj  the  primary  stroke  of  the  pulse.     Of  these 


164  Circulatory  System. 

the  most  noteworthy  is  that  known  as  the  dicrotic 
wave.  It  is  best  marked  in  pulses  of  low  tension 
(provided  there  is  not  aortic  regurgitation)  and  is 
most  readily  felt  when  the  finger  is  very  lightly  ap- 
plied to  the  vessel.  Where  not  readily  perceived 
it  is  often  accentuated  by  occluding  the  vessel  on  the 
distal  side  by  the  lower  finger  whilst  the  middle  and 
upper  ones  remain  lightly  applied. 

The  secondary  wave  which  the  finger  detects  with 
the  next  greatest  frequency  is  the  tidal  or  pre- 
dicrotic  wave.  It  occurs  in  certain  pulses  of  high 
tension  where  the  blood  escapes  slowly  from  the  con- 
tracting ventricle,  and  is  very  characteristically  present 
in  aortic  stenosis.  In  opposition  to  the  dicrotic  wave, 
it  is  best  felt  when  considerable  pressure  is  applied 
to  the  artery,  and  thus  there  is  no  difficulty  in  dis- 
criminating between  the  two. 

Besides  these,  in  pulses  of  high  tension,  there  are 
frequent  fluctuations  of  pn^ssure  at  a  period  subse- 
quent to  that  in  which  the  dicrotic  wave  occurs. 

These  can  sometimes  be  detected  by  the  fingers, 
but  it  requires  much  practice  to  recognise  them. 
They  are  visible  enough  in  good  sphygmographic 
tracings. 

The  typical  pulse  of  a  healthy  adult  man  should 
be  described  in  some  such  terms  as  the  following  : — 

The  rate  is  seventy  per  minute. 

The  beats  are  regular  in  rhythm  and  equal  in 
force. 

The  expansion  is  moderate  in  amount. 

The  vessel  is  not  tortuous,  its  walls  are  not  rigid 
or  thickened,  and  between  the  beats  it  is  just  possible 
to  feel  it.     It  is  of  medium  size. 

Tension. — The  passage  of  the  pulse-wave  can  be 
arrested  by  moderately  firm  pressure,  and  the  beat  is 
best  felt  when  a  medium  degree  of  pressure  is  applied. 

Cbaracter.  —  The   rise   of   pressure   is   neither 


The  Sphygmograph.  165 

abrupt  nor  very  gradual,  it  is  fairly  well  sustained, 
and  its  fall  is  gradual,  but  not  very  tardy.  No 
conspicuous  oscillations  of  pressure  are  discernible 
during  the  time  of  subsidence. 

SECTION     VII.  —  THE     USE     OF     THE    " 
SPHYGMOGRAPH. 

For  permanent  record,  and  also  to  aid  in  the  ana- 
lysis of  details,  it  is  important  to  employ  a  sphygmo- 
graph as  well  as  to  feel  the  pulse  in  all  cases  where 
the  state  of  the  heart  and  vessels  is  an  important 
factor.  Numerous  types  of  sphygmograph  are  now  in 
use,  but  only  Marey's  and  Dudgeon's  will  be  described 
here,  as  they  are  most  frequently  employed. 

In  Marey's  spliyg:niog^rapli  the  pad  which 
rests  on  the  artery  acts  on  a  long  lever  the  farther 
end  of  which  traces  the  pulse  curve  on  smoked  paper, 
that  is  held  in  a  frame  driven  by  clockwork.  In 
Dudg^eoii's  the  same  result  is  obtained  by  connect- 
ing two  shorter  levers  in  such  a  manner  as  to  magnify 
the  movement  of  the  pad  fifty  times.  The  end  of  the 
lever  in  Marey's  instrument  describes  the  arc  of  a 
circle  ;  in  Dudgeon's,  owing  to  the  mechanical  device 
employed,  the  style  moves  backv/ards  and  forwards  in 
a  straight  line.  The  following  description  of  the 
method  of  using  each  will  aid  the  student  in  applying 
them  : — 

I.  Marey's  instrument :  The  patient  should  sit 
or  lie  down.  Place  the  arm  support  on  a  table  of 
suitable  height  beside  the  patient.  Loosen  any  tight 
garments  about  the  patient's  arm,  which  must  be 
bared  to  above  the  elbow.  Place  the  arm  supine 
on  the  support,  with  the  back  of  the  wrist  at  the 
highest  part.  Semiflex  the  fingers.  Mark  the  line 
of  the  radial  on  the  skin,  and  draw  a  cross  line  where 
the  pad  of  the  sphygmograph  is  to  rest.  Wind 
the  clockwork   and   adjust  the  paper  on  the  instru- 


1 66  'Circulatory  System. 

ment.*  Place  the  pad  of  the  sphygmograph  very 
accurately  in  position,  with  the  lever  pointing  up 
the  arm  towards  the  elbow,  and  fix  the  instrument  in 
its  place  by  non-elastic. bands.  Adjust  the  pressure 
of  the  pad,  by  means  of  the  screw  or  milled  head, 
until  the  lever  affords  the  maximum  range  of  move- 
ment. Adjust  the  level  of  the  style,  after  re-coupling 
it  with  the  pad,  so  that  the  movement  of  the  lever 
takes  place  opposite  the  smoked  paper,  and  see  that 
the  style  is  in  contact  with,  but  does  not  press  too 
heavily  on  the  latter.  Before  varnishing  the  trace, 
note  patient's  name,  date  (and  time  of  day),  whether 
right  or  left  radial,  pulse  rate,  respiration,  and  ap- 
proximate pressure  employed.!  Ordinary  quick-drying 
negative  varnish,  as  used  by  photographers,  is  em- 
ployed to  fix  the  trace,  the  paper  being  dipped  into  a 
jar  of  varnish,  or  laid,  trace  upwards,  in  a  saucer 
containing  some. 

II.  Dudgeon's  instrument  is  used  as  follows  : — 

1.  Wind  up  the  clockwork. 

2.  Insert  one  end  of  the  smoked  paper  (smoked 
side  uppermost)  on  the  righthand  side  of  the  in- 
strument between  the  roller  and  small  wheels. 

3.  Make  the  patient  hold  out  either  hand  open, 
and  in  an  easy  position,  palm  upwards,  the  fingers 
pointing  towards  you,  and  tell  him  not  to  move  the 
wrist  or  fingers. 

4.  Ascertain  and  mark  the  precise  spot  where  the 
radial  artery  beats  at  the  wrist. 

5.  Slip  the  band,  the  free  end  of  which  has 
been  drawn  through  the  clamp,  over  the  patient's  hand. 

6.  Adjust  the  pressure  of  the  spring. 

*  The  paper  is  best  smoked  over  a  small  piece  of  burning  cam- 
phor, which  may,  if  necessary,  be  moistened  with  a  drop  of  alcohol. 

f  The  nominal  pressure  as  given  by  the  index  on  the  screw  is 
not  even  approximately  correct,  but  if  the  same  instrument  is 
always  used  the  results  are  comparable  to  some  extent. 


The  Sphvgmograph.  167 

7.  Place  the  pad  on  the  artery,  the  clockwork 
case  being  nearest  the  elbow. 

8.  Retain  the  instrument  in  place  with  the  right 
hand  ;  tighten  the  band  sutficiently  with  the  left,  and 
clamp  by  means  of  the  screw  with  the  right  hand. 
When  the  band  is  correctly  tightened,  the  needle  will 
oscillate  over  the  paper.  If  the  tightness  is  nearly 
but  not  quite  correct,  bend  the  hand  backw^ards  at 
the  wrist  to  increase  the  tension,  or  forwards  to 
diminish  it. 

9.  Set  the  paper  in  motion  by  releasing  the  catch 
that  controls  the  clockwork. 

10.  Let  the  paper  run  through  unassisted,  and 
catch  it  in  your  hand  as  it  passes  from  the  instrument. 
Generally  the  patient's  hand  must  be  supported  whilst 
the  tracing  is  taken. 

11.  Stop  the  clockwork  as  soon  as  the  paper 
has  passed. 

In  a  pulse  tracing  rise  of  blood  pressure  will  be 
represented  by  an  upstroke,  and  fall  by  a  downstroke. 

Bearing  this  in  mind  the  student  will  readily 
understand  the  main  outlines  of  a  healthy  pulse 
tracing.  The  pressure  rises  fairly  rapidly  ;  therefore 
the  upstroke,  when  the  paper  is  driven  forward  at 
the  usual  speed,  is  nearly,  but  not  quite  perpendicular. 
The  percussion  wave  is  quickly  followed  by  what  is 
known  as  the  tidal  (or  pre-dicrotic)  wave ;  these  are 
not  separately  distinguishable  by  the  finger  in  health, 
the  sphygmograph,  however,  indicates  their  existence 
by  a  notch  at  the  beginning  of  the  downstroke. 
Thereafter  the  pressure  begins  to  fall  ofl*,  but,  at  the 
moment  when  the  aortic  valves  close,  the  decrease  of 
pressure  is  arrested,  and  a  positive  (dicrotic)  wave  is 
propagated  into  the  vessels  :  this  condition  is  recorded 
by  a  small  break  in  the  descent  of  the  downstroke  of 
the  tracing.  The  foot  of  the  notch  immediately 
before  the  dicrotic  upstroke  indicates  the  time  when 


1 68  Circulatory  System. 

the  aortic  valves  close.  After  this  rise  the  line  again 
curves  downwards,  often  exhibiting  slight  secondary- 
oscillations,  until  a  new  upstroke  marks  the  arrival  of 


Fig.  44.— Normal  forms  of  pulse.     (Mahomed.) 

the  next  pulse-wave.  Ordinarily  the  blood  pressure 
takes  much  longer  to  fall  than  to  rise,  hence  the 
downstroke  is  much  less  vertical  than  the  upstroke 
(Fig.  44). 


The  Sphygmograph.  169 

In    healtli    a    pulse    tracing    taken  with    suitable 
pressure,  has  a  sharp  apex,  a  small  tidal  wave,  and  a 


Fig.  45.— Low-tension  pulse 


moderately  distinct  dicrotic  wave.     A  rounded  apex, 
in  most  cases,  means  either  excessive  pressure  of  the 


Fig.  -16.— High-tension  pulse. 


spring    or   bad    application    of    the   instrument    (see 
however  p.  171). 

The  upstroke  is  longer  and  steeper  than   usual, 
when   the   ventricle    discharges    a    larger  volume    of 


170 


ClRC ULA  TOR  y   SVS TEM. 


blood  than  normal  into  the  arteries,  and  when  the 
arterioles  are  dilated  (low  tension)  (Fig.  45). 

The  upstroke  is  shorter  and  less  steep  when  the 
heart  acts  feebly  or  when  the  aortic  ostium  is 
stenosed,  so  that  less  blood  than  usual  is  delivered  in 
a  given  time,  and  also  when  the  blood  |>ressure  is  high 
and  undue  opposition  is  thereby  offered  to  the  outflow 
from  the  heart  (Fig.  46). 

In  conditions  where  the  minimum  blood  pressure 


Fig.  47.— Aortic  stenosis. 

is  low,  the  dicrotic  wave  is  well  marked ;  where  it  is 
high,  the  dicrotic  wave  is  small,  and  secondary 
oscillations  are  present. 

The     following     conditions     give     characteristic 

tracings  : — 

1.  Aortic  stenosis.  Small  amplitude,  sloping 
upstroke,  tidal  wave  well  developed,  and  often  higher 
than  primary  apex  (Fig.  47). 

2.  Aortic  iiicompeteiice.  Great  amplitude, 
abrupt  upstroke,  rapid  fall,  little  or  no  dicrotic  wave. 
This  is  known  as  the  water-hammer,  collapsing,  or 
Corrigan  pulse  (Figs.  48,  49). 

3.  Mitral  disease.  Small  amplitude,  moderately 
steep  upstroke,  secondary  waves  rather  slight, 
successive    beats    unequal    and    irregular,    especially 


The   Sphygmograph.  171 

when  failure  of  heart  is  threatening  to  set  in.  In 
mitral  stenosis  the  vascular  tension  tends  to  be 
higher  than  in  mitral  incompetence  (Fig.  50). 

4.  Aiieiirysiii  of  the  ascendino-  or  transverse 
aorta  generally  aftects  the  pulse  in  the  implicated 
radial,  where  the  impulse  is  delayed,  whilst  the  rise 


Fig.  48. — Aortic  incompetence. 

is  gradual,  the  amplitude  less,  and  the  apex  rounder 
than  in  the  unaffected  radial  (Fig.  51). 

5.  Arterial  atheroma  of  the  great  vessels  by 
abolishing  the  modifying  effect  of  their  elasticity, 
renders  the  tracing  similar  to  one  taken  from  the 
pressure  curve  of  the  left  ventricle.  This  is  known 
as  the  senile  pulse  (Fig.  52).  Aortic  atheroma  com- 
bined with  a  moderate  degree  of  incompetence,  gives 


172 


Circulatory  System. 

a  pulse  which  is  like  that  of 
atheroma,  but  with  sharper  apex. 

Several  types  of  pulse  have 
received  special  names,  of  these 
the  following  are  amongst  the  more 
important : — 

1.  Piilsuis  bisferiens.  The 
tidal  wave  is  felt  separately  from 
the  primary  impact.  The  tracing 
is  characteristic  (Fig.  53). 

2.  Pulsus  dicroticiis.  The 
i  dicrotic  wave  is  exaggerated  (see 
I  p.  164)  (Fig.  54). 

3.  Pulsus  celer.  The  pres- 
;  sure  is  ill  sustained,  the  up  and 
I  down  strokes  are  therefore  abrupt. 
I*  4.  Pulsus  tardus.  The  pres- 
\  sure  is  well  sustained,  the  tracing 
\  is  less  abrupt.  This  is  sometimes 
;  described  as  a  "  long  "  pulse. 
\  5.  Pulsus  bigfeminus.  There 
\  are  two  beats  and  a  pause.  The 
\  two  beats  may  be  alike,  or  they 
>  may  differ  in  force  (Fig.  42). 
'  6.  Pulsus  trigeminus. 
'  Three  beats  and  a  pause  (Fig.  43). 
j'  7.  Pulsus  paradoxus.   The 

pulse  becomes  smaller  or  disappears 
at  the  end  of  inspiration,  when 
the  patient  breathes  deeply.  It 
occurs  in  pericardial  adhesion. 

8.  The  pulse  is  described  as 
"n'iry"  when  the  vessels  are 
contracted  and  the  heart  beat 
rapid  and  moderately  strong.  This 
may  occur  in  peritonitis.  When 
the   heart   gets  weak,   whilst  the 


The  Sphvgmograph. 


173 


Fig.  50. — Mitral  incompetence 


Left  side. 


Right  side. 
Fig.  51. — Pulse  in  aneurysm. 

otlier  conditions  continue,  the  pulse  grows  "thready," 
but  at  the  same  time  the  blood  pressure  generally 
begins  to  diminish. 

9.  The  pulse  is  said  to  be  *'  running  "  when  the 
vessels  are  relaxed,  and  the  heart's  action  is  weak  and 
fairly  rapid. 


Circulatory  System. 


Fig.  52. — Aortic  atheroma  (senile  pulse). 


Fig.^53. — Pulsus^bisferiens. 


Fig.  54.— Dicrotic  pulse. 


The   Venous  Pulse.  175 

SECTION  VIIL— THE  VENOUS   PULSE. 

In  a  considerable  number  of  cases  where  the  cir- 
cuhition  of  blood  through  the  right  side  of  the  heart 
is  interfered  with,  either  from  valvular  disease  or 
from  increased  blood  pressure  in  the  pulmonary 
circulation,  the  embarrassment  manifests  itself  by 
distention  or  pulsation  in  the  veins.  From  their  size, 
nearness  to  the  heart,  and  comparatively  superficial 
situation,  the  veins  of  the  neck  offer  special  facilities 
for  the  study  of  these  phenomena. 

Wliilst  inspecting  the  root  of  the  neck,  the 
observer  has  already  had  an  opportunity  of  noting 
these  appearances  where  they  exist,  but  the  several 
varieties  and  deojrees  of  disturbance  in  the  venous 
circulation  must  now  be  more  completely  distin- 
guished. A  mere  flicker  of  pulsation  at  the  root  of 
the  neck  when  the  patient  is  recumbent,  is  common 
enough  even  in  perfect  health,  and  must  not,  in  the 
absence  of  further  evidence,  be  regarded  as  indicating 
any  disease  of  the  heart.  When,  however,  the  pulsa- 
tion passes  farther  up,  the  case  is  entirely  altered. 
Two  points  must  then  be  noted — first,  whether  there 
is  actual  regurgitation,  or  merely  retarded  emptying  of 
a  full  vein  during  the  beat  of  the  heart ;  and  second, 
the  exact  moment  at  which  the  pulsation  occurs  with 
reference  to  the  apex  beat.  Sometimes  there  is  no 
difficulty  in  distinguishing  between  regurgitation 
and  simple  uiidiilatioo  in  the  vein.  In  bad  cases 
of  tricuspid  incompetence,  a  mere  glance  at  the 
patient  will  at  once  reveal  the  nature  of  the  pheno- 
menon. Where  the  conditions  are  less  urgent,  and 
the  distinction  is  less  readily  determined,  a  simple  plan 
is  to  empty  the  vein  from  below  upwards  by  running 
the  finger  along  it,  and  then  keeping  its  upper 
extremity  closed  by  the  pressure  of  the  finger,  so  that 
no  blood  can  enter  it  from  the  periphery. 


176  Circulatory  System. 

In  cases  of  simple  undulation,  the  vessel  either 
remains  empty  and  collapsed,  or  at  most  re-fills  very 
gradually,  as  small  collateral  branches  discharge  their 
contents  into  it.  Where,  however,  there  is  true 
pulsation,  the  valves  at  the  root  of  the  neck  have 
ceased  to  be  competent.  As  a  consequence  of  this, 
coupled  with  the  overloaded  state  of  the  right  heart, 
a  backward  wave  of  blood  is  forced  into  the  vein, 
which  re-fills  from  below  with  a  series  of  bounds 
corresponding  to  the  beats  of  the  heart,  and  after 
three  or  four  pulsations  is  again  distended  and 
pulsating  as  vigorously  as  ever,  although  the  ob- 
server's finger  continues  to  maintain  the  peripheral 
closure. 

Regarding  the  time  of  occurrence  of  the  venous 
pulse  a  great  divergence  of  opinion  has  existed. 
Recent  observations  *  lead  to  the  following  conclu- 
sions :— A  large  wave  is,  in  typical  cases,  driven  back 
during  auricular  systole ;  a  short  time  after  it  has 
obtained  its  highest  pressure,  and  when  it  is  just 
beginning  to  fall  off  it  is  reinforced  by  the  shock 
which  the  carotid  pulse  imparts  to  all  the  adjacent 
structures.  Thereafter  the  pressure  again  falls,  and 
often  reaches  its  minimum  during  the  earlier  part  of 
ventricular  systole,  when  the  obstacles  to  the  entrance 
of  blood  into  the  auricle  seem  to  be  less  marked. 
The  pressure  again  rises  near  the  end  of  ventricular 
systole,  the  exact  time  of  this  second  rise  depending, 
on  the  one  hand,  on  the  amount  of  tricuspid  leakage 
— or  in  some  cases  perhaps  of  mere  backward  yielding 
of  the  tricuspid  curtains  without  leakage — and  on  the 
other,  on  the  activity  of  the  auricle  \  it  then  falls  off 
somewhat  during  ventricular  diastole  to  rise  once 
more  at  the  commencement  of  the  next  cardiac  cycle 
with    auricular    systole.     These    conditions    may    be 

*  James  Mackenzie,    "Pulsations  in  the  Veins."    Joum.  of 
Pathology  and  Bacteriology,  vol.  I.,  p.  53. 


The   Venous  Pulse. 


177 


traced  in  relation  to  the  events  of  the  cardiac  cycle, 
when  the  sequence  will  resemble  that  of  the  accom- 
panying diagram,  where  the  upper  tracing  represents 
the  movement  of  the  recording  lever  of  a  suitably 
adjusted  tambour  applied  to  the  pulsating  vein,  whilst 
the  lower  part  indicates  the  events  in  the  cardiac 
cycle,  which  correspond  to  the  various  parts  of  the 
curve  so  obtained  (Fig.  55). 

The  details  of  individual  tracings  differ  greatly  in 
some  one  part  of  the   curve,  in  others  another  being 


specially  emphasised.     For  details   the  original  paper 
must  be  consulted. 

In  certain  circumstances  a  venous  pulse  of  totally 
different  origin  may  be  present.  This  is  known 
as  the  centripetal  venous  pulse,  and  is  due 
either  to  great  dilatation  of  the  arterioles,  so  that  the 
arterial  pulse  passes  through  the  capillaries  and  is 
visible  even  in  the  veins,  or  to  an  aneurysmal  varix, 
whereby  direct  communication  occurs  between  an 
artery  and  vein,  and  the  pulse-wave  of  the  artery 
reaches  the  vein  by  this  channel.  The  observer  can 
have  no  great  difficulty  in  recognising  the  nature  of 
such  centripetal  pulsation. 

M 


178  Circulatory  System. 

SECTION  IX.— SYMPTOMS   OF  THE   PRIN- 
CIPAL  DISEASES  OF   THE   HEART. 

1.  Valvular  diseases. — (a)  Aortic  iiicompe- 
fence.  The  patient  complains  of  attacks  of  giddi- 
ness, is  often  pale,  and  his  arteries  pulsate.  Capillary 
pulsation  may  be  observed.  The  apex  beat  is  dis- 
placed downwards  and  outwards,  and  has  a  heaving 
character.  The  left  border  of  the  heart  is  farther  out 
than  usual.  A  murmur  accompanies  the  second 
sound,  as  has  been  elsewhere  described,  and  the  pulse 
exhibits  a  "water-hammer"  character. 

(6)  Aortic  stenosis.  Here  the  apex  beat  is 
rather  weak,  and  the  displacement  less  notable  than 
in  the  last  condition.  The  arteries  are  small,  and  the 
tension  of  the  pulse,  before  compensation  is  destroyed, 
is  somewhat  high.  Vertigo  or  fainting  fits  are  not 
uncommon.  The  murmur  is  described  on  p.  148. 
The  aortic  second  sound  is  very  weak. 

(c)  Mitral  incompetence.  This  condition  is 
often  associated  with  dyspnoea,  which  is  the  first 
symptom  of  which  the  patient  may  complain.  The 
face  is  apt  to  be  cyanotic.  The  apex  beat  is  of 
moderate  strength,  and  is  frequently  displaced  out- 
wards. On  auscultation,  in  addition  to  the  character- 
istic murmur,  one  finds  marked  accentuation  of  the 
second  sound  in  the  pulmonary  area. 

{d)  Mitral  stenosis.  Here  the  stress  falls  chiefly 
on  the  left  auricle  and  right  side  of  the  heart.  The 
apex  beat  is  therefore  only  slightly  displaced  out- 
wards, and  is  not  unduly  vehement.  The  murmur  is 
very  frequently  accompanied  by  a  thrill,  and  in  many 
cases  the  second  sound  as  heard  at  the  apex  is  re- 
duplicated. The  pulse  is  at  first  not  notably  affected, 
but  gradually  becomes  irregular  and  feeble  as  com- 
pensation fails. 

(/?)  Tricuspid  incompetence,  which  is  usually 


Heart  Diseases.  179 

secondary  to  mitral  disease,  is  associated  with  dilata- 
tion of  the  right  auricle,  and  consequently  with 
outward  displacement  of  the  right  border  of  the  heart, 
with  venous  and  hepatic  pulsation,  and  with  dropsy. 
The  murmur  has  already  been  described  ;  the  second 
sound  in  the  pulaionary  area  is  weak.  The  patient 
usually  suffers  from  very  decided  dyspncea. 

2.  Idiopalliic  lieart  diseases  lead  at  first  to 
hypertrophy  and  dilatation  of  the  ventricles,  sub- 
sequently to  fatty  changes  in  the  myocardium.  The 
physical  signs  will  obviously  vary  with  the  stage  of 
the  disease,  and  are  frequently  somewhat  hard  to 
interpret.  Like  all  other  forms  of  heart  disease,  they 
terminate  in  failure  of  compensation,  with  its  accom- 
paniments of  dyspnoea,  urinary  deficiency,  dropsy,  and 
cyanosis. 

3.  Pericarditis  is  characterised  by  jDain  in  the 
chest,  more  or  less  fever,  and  by  friction  of  a  to-and- 
fro  character  when  eflusion  is  scanty.  When  more 
fluid  has  been  poured  out,  the  area  of  dulness  is 
triangular  and  oversteps  the  second  left  interspace. 
The  apex  beat  is  internal  to  the  left  limit  of  duluess, 
and  may  be  weak  or  quite  unable  to  be  felt.  The 
pulse  may  be  greatly  affected,  and  it  is  by  this 
disease  that  the  "  pulsus  paradoxus  "  is  produced. 

4.  Intratlioracic  aneurysm  of  the  aorta  leads 
in  some  cases  to  a  tumour  at  the  upper  part  of  the 
chest,  which  is  dull  on  percussion,  and  in  which 
expansile  pulsation  can  often  be  observed.  It  may 
also  affect  the  character  and  synchronism  of  the  pulses 
at  the  two  wrists.  The  auscultatory  phenomena  are 
very  variable.  It  produces  numerous  symptoms  by 
involvement  of  different  structures  upon  which  it 
comes  to  press  as  it  enlarges. 

5.  Cardiac  Asthma.  This  condition  is  charac- 
terised by  attacks  of  severe  dyspncea,  often  lasting 
for  several  hours  on  end.     The  patient  is  so  breathless 


i8o  Circulatory  System. 

that  he  requires  to  sit  up,  and  may  have  to  call  the 
accessory  respiratory  muscles  into  violent  exercise. 
It  is  distinguished  from  bronchial  asthma  by  the  state 
of  the  heart,  which  is  generally  dilated,  and  whose 
apex  beat  is  weak.  The  pulse  also  is  small,  rapid,  and 
irregular,  and  the  dyspnoea  is  not  of  the  pure  expira- 
tory type  which  characterises  asthma  of  respiratory 
origin. 


i 


i8i 


CHAPTER   V. 
Clinical  Examination  of  the  Blood. 

Eiiiinieratiou  of  red  blood  corpuscles.— This 

may  be  done  by  means  of  either  a  Thoma-Zeiss 
or  a  Cowers'  hsemocytometer.*  The  former  is  the 
simpler  and  more  accurate  instrument.  We  shall 
describe  it  first. 

1.  Thoma-Zeiss  lisemocyto- 
metei*. — The  instrument  consists  of 
a  mixing  pipette  (Fig.  56)  suitably 
graduated  and  a  counting  slide. 
Cleanse  the  lobe  of  the  patient's  ear 
with  soap  and  water,  dry  it,  and  rub 
it  a  little  between  the  finger  and 
thumb  in  the  drying,  so  as  to  render 
it  hypersemic.  Make  a  puncture  on 
the  lower  border  of  the  lobe  by  means 
of  the  lancet-shaped  needle  supplied 
with  the  instrument.  The  needle 
should  be  inserted  with  a  rather 
sudden  stab — not  too  slowly — and 
the  blood  must  flow  freely.  On  no 
account  must  the  blood  be  squeezed 
out,  as  it  is  theii  always  diluted  by 
lymph  squeezed  out  of  the  tissues. 
Slowly  suck  up  blood  by  means  of 
the  pipette  till  either  the  mark  0.5 
or    1    is    reached.       If    one    should 


u 


*  A  new  form  of  hsemocytometer  has  beeu 
introduced  by  Dr.    George    Oliver,   but   the 

authors  have   had   no  experience  of  its  use.  V 

It  is  supplied,  along  with  full  directions,  by     pjo-  55, Hjeniocy- 

the   Tintometer   Company,    Limited,   6,   Far-  tometer      pipette 

ringdon  Avenue,  London,  E.G.  (Thoma-Zeiss). 


1 82  The  Blood. 

happen  to  go  a  little  beyond  the  05  mark,  the 
column  of  blood  should  be  gently  blown  down 
to  the  proper  point.  If  blood  has  been  sucked  past 
the  mark  1,  it  has  reached  the  mixing  chamber,  and 
the  process  must  be  begun  over  again.  Having 
charged  the  pipette,  wipe  the  end  of  it  on  a  clean 
cloth,  and  plunge  it  at  once  into  the  diluting  fluid 
(Appendix,  17),  which  should  be  standing  ready  in 
a  small,  wide-necked  bottle  with  the  stopper  out. 
Suck  up  the  diluting  fluid  as  far  as  the  mark  101. 
Whilst  doing  so,  the  pipette  should  be  gently  rotated 
so  as  to  start  the  mixing.     Seize  the  pipette  firmly 


:^^;^^g|  n^;^ — TfL i  I    «$^1 


'W/'///////y//////////,  /'/^y /////', 


Fig.  57.— Thoma-Zeiss  Counting  Slide, 
s,  slide ;  m,  platform ;  c,  wall  of  trench. 

by  its  ends  between  the  forefinger  and  thumb,  and 
shake  thoroughly  for  about  one  minute.  This  pro- 
duces a  thorough  mixing  of  the  blood  with  the  fluid. 
It  must  be  remembered  that  the  column  of  diluting 
fluid  which  occupies  the  capillary  part  of  the  pipette 
does  not  enter  into  the  mixture.  Hence,  if  blood 
is  sucked  up  to  0*5,  the  dilution  produced  is  in  the 
proportion  of  1  in  200,  whereas  if  blood  is  taken 
up  to  the  mark  1,  the  dilution  is  only  1  in  100.  The 
former  degree  of  dilution  is  to  be  preferred  in  most 
cases.  The  finger  should  now  be  removed  from  the 
pipette,  and  the  diluting  fluid  in  the  capillary  tube 
blown  out.  After  a  few  drops  of  the  diluted  blood 
have  been  shaken  out,  a  small  drop  is  transferred  to 
the  counting  slide  (Fig.  57).  The  latter  consists  of  a 
small  platform  (m)  bounded  by  a  trench  which  is 
surrounded  by  a  glass  slab  (c).  On  the  surface  of  the 
platform  microscopic  squares  are  ruled,  each  having 
an  area  of  -^^  square  millimetre.  Special  cover 
glasses,  carefully   ground,   are   supplied,    which   rest 


Counting  the  Red  Corpuscles.         183 

upou  the  glass  slab,  a  space  being  left  between  the 
under-surface  of  the  cover  and  the  surface  of  the  plat- 
form, which  space  is  exactly  y^  millimeter  in  depth. 

The  drop  of  diluted  blood  should  be  placed  in  the 
centre  of  the  platform,  and  should  be  of  such  a  size 
that  when  the  cover  glass  is  placed  in  position  the 
drop  is  flattened  out  so  as  to  cover  most  of  the  surface 
of  the  platform,  but  yet  without  any  of  it  flowing 
over  the  edge  into  the  trench.  It  requires  a  little 
experience  to  enable  one  to  take  just  the  proper  size 
of  drop.  It  is  important  that  the  cover  glass  should 
lie  quite  flat  upon  the  glass  slab.  This  can  best  be 
achieved  by  previously  washing  both  it  and  the  slab 
with  caustic  potash,  so  as  to  remove  all  grease,  and  then 
rubbing  them  with  soft  chamois  leather.  The  cover 
must  be  lowered  into  position  by  means  of  a  needle. 
One  recognises  that  the  cover  glass  is  lying  properly 
by  the  appearance  of  concentric  colour  (Newtonian) 
rings  betv/een  it  and  the  slab.  The  rings  should  be 
visible  when  the  cover  is  simply  lying  on  the  slab 
Avithout  any  pressure  being  exerted.  The  rings  are 
best  seen  by  looking  horizontally  along  the  surface  of 
the  cover.  If  they  are  not  visible  at  first  gentle 
pressure  on  the  cover  glass  often  brings  them  out. 
Unless  the  rings  are  seen,  one  cannot  be  sure  that 
the  space  between  the  cover  and  the  platform  is 
exactly  -^  millimetre  in  depth.  Having  placed  the 
drop  in  position,  and  the  rings  being  visible,  one 
should  set  the  preparation  aside  for  five  minutes  or 
so,  to  enable  the  corpuscles  to  settle.  It  should  then 
be  examined  with  the  low  power  to  see  whether  any 
air  bubbles  or  foreign  bodies  are  present,  and  whether 
the  corpuscles  are  distributed  with  fair  uniformity 
throughout  the  field,  after  which  the  high  power  is 
used  for  counting.  The  little  squares  will  be  seen  to 
be  marked  oflf  into  sets  of  sixteen  by  double  ruling 
(Fig.  58).    Should  the  lines  marking  off  the  squares  be 


1 84 


The  Blood. 


t     ?  f  1 .    I      1     ■      \ I — -■ 

*o°o°  °° »:  *  •  ,*  •'  'o '  K  °  %  *° »  \% 

•  o         oo       OO  oO*o       O    «     O    00    *       0       * 

O   **         o  o  «        o       O  O  oo      o    '^  0     o 

•  o      »      ~    ^        o"    ^     1^      ^    O        O     °         ,      'O  O    J 

"        o        ~rj  — 5"^'^ Z 7'g~  ,    o  o ^"0     o    „ 

*  ■«■■   ^1^  OB^  -^—Mi—S—  ^a      °  ^' 

-' — IH-i 1 — 4^^ — I — ■■!  1  t- — \ 


Fig.  58. — Microscopic  View  of  Thoma- 
Zeiss  countins-slide  showing  divisions. 


only  dimly  seen,  it  may  be  necessary  to  intensify  them. 
This  is  best  done  by  rubbing  the  surface  of  the  plat- 
form with  a  little  finely  powdered  graphite — e.g.  the 
scrapings    from    a    very    soft   lead  pencil — and    then 

,     polishing     it     with    soft 
chamois  leather. 

For  enumeration  of 
the  red  cells,  at  least  three 
sets  of  sixteen  squares 
should  be  counted.  The 
squares  in  each  set  should 
be  gone  over  systematic- 
ally in  horizontal  rows  of 
four  at  a  time.  Of  the 
corpuscles  which  lie  wpon 
the  lines  bounding  the 
row  only  those  on  the 
upper  and  on  the  left 
hand  lines  should  be  counted. 

Calculation. — Count  the  corpuscles  in  each  of  the 
four  horizontal  rows  from  above  downwards.  The 
total  is  the  number  of  corpuscles  in  sixteen  squares. 
Count  in  this  way  three  sets  of  sixteen,  and  divide 
the  total  by  forty-eight,  which  gives  the  average  of 
cor[)Uscles  in  one  square.  But  the  dimensions  of 
this  square  are  ^^^  X  yV  ^^  toVo  cubic  millimetre. 
Therefore,  if  there  be  x  corpuscles  in  this  dimension, 
there  will  be  4,000  x  in  1  cram.  But  the  blood  was 
diluted  200  (or  100)  times.  Therefore,  in  1  cmm. 
of  blood  there  will  be  4,000  a;  x  200  (or  100)  cor- 
puscles. 

Suppose,  for  example,  that  one  finds  a  total  of 
288  corpuscles  in  the  forty-eight  squares.  This  gives 
an  average  of  six  corpuscles  per  square,  or  6  X  4,000 
— i.e.  24,000  per  cmm.  of  diluted  blood,  or  4,800,000 
per  cmm.  of  pure  blood,  if  the  dilution  was  one  in 
two  hundred. 


k 


Counting  the  Red  Corpuscles.  185 

The  constant  error  in  the  Thoma-Zeiss  instrument 
is  less  than  1  per  cent,  of  the  total  result.  The 
variable  error  depends  upon  the  number  of  corpuscles 
counted.  By  counting  200  corpuscles,  it  amounts  to 
5  per  cent,  of  the  total;  by  counting  5,000  it  amounts 
to  only  1  per  cent.  To  count  the  whole  256  squares 
takes  about  half  an  hour.  This  usually  means 
counting  1,200-1,500  corpuscles.  The  co-efficient  of 
error  is  then  about  2  per  cent. 

2.  Oowers'  haeiiiocytoniefer. 

The  instrument  consists  of  a  capillary  tube 
graduated  for  5  cmm.,  and  a  pipette  graduated  for 
995  cmm.,  a  mixing  vessel  and  stirrer,  and  a  counting- 
slide. 

Take  up  995  cmm.  of  diluting  fluid  (Appendix,  17) 
in  the  pipette  and.  transfer  it  to  the  mixing  vessel. 
Suck  up  5  cmm.  of  blood  in  the  capillary  tube  and 
gently  blow  it  into  the  above  quantity  of  fluid. 
Mix  the  two  very  thoroughly  by  rotating  the  stirrer 
between  the  finger  and  thumb.  The  blood  is  now 
diluted  in  the  proportion  of  1  in  200.  Transfer  a 
drop  of  the  mixture  to  the  centre  of  the  ruled  area 
on  the  counting-slide,  cover,  and  fix  the  cover  glass 
with  the  clips.  The  ruled  area  is  divided  into  squares 
of  -^^  mm.  square,  and  the  space  between  the  sur- 
face of  a  square  and  the  under  surface  of  the  cover 
glass  is  \  mm.  in  depth.  Count  the  corpuscles  in 
ten  squares.  The  result  multiplied  by  10,000  is  the 
number  of  red  cells  in  a  cubic  millimetre  of  undi- 
luted blood. 

The  normal  number  of  red  corpuscles  is 
5,000,000  per  cmm.  In  some  full-blooded  adults  this 
number  may  be  exceeded.  In  females,  even  in  health, 
it  is  usually  rather  smaller  (about  4,500,000).  The 
blood  of  newly  born  children  sometimes  contains 
more  than  5,000,000,  and  that  number  is  also  sur- 
passed in  cases  of  prolonged  cyanosis. 


1 86  The  Blood. 

The  number  is  reduced  in  all  forms  of  anaemia. 
In  chlorosis,  however,  the  number  of  corpuscles  may 
be  normal  or  nearly  so. 

Eniimeration  of  JLcucocyte^s. 

A  special  pipette  is  supplied  for  this  purpose  with 
the  Thoma-Zeiss  instrument.  It  is  used  in  precisely 
the  same  manner  as  the  red-corpuscle  pipette,  but 
permits  of  a  lesser  degree  of  dilution  of  the  blood. 
The  best  diluting  fluid  to  employ  is  0*3  per  cent, 
solution  of  acetic  acid  to  which  enough  of  a  watery 
solution  of  methyl  green  has  been  added  to  give  the 
mixture  a  decided  green  colour.  The  advantage  of 
this  mixture  is  that  it  dissolves  all  the  red  cells 
while  it  stains  the  nuclei  of  the  white.  One  can  thus 
easily  count  the  whites,  and  at  the  same  time  note 
the  relative  numbers  of  the  uni-  and  multi-partite 
nucleated  varieties. 

It  is  important  that  a  large  drop  of  blood  should 
be  allowed  to  exude  before  one  begins  to  fill  the 
pipette.  The  blood  should  be  sucked  up  to  the  mark 
0-5_,  the  end  of  the  pipette  wiped,  and  diluting  fluid 
taken  up  to  the  mark  101. 

Owing  to  the  relatively  large  calibre  of  the 
pipette,  the  blood  is  apt  to  run  out  of  it.  It  is  well, 
thei-efore,  to  keep  the  pipette  in  a  horizontal  position 
as  soon  as  one  has  filled  it  with  blood. 

The  blood  and  the  fluid  are  mixed  as  already 
described.  This  produces  a  dilution  of  1  in  20.  A 
drop  is  then  placed  on  the  counting-slide  with  the 
same  precautions  that  were  observed  in  the  case  of 
the  red  cells. 

In  this  case  the  whole  sixteen  sets  of  sixteen 
squares  should  be  counted,  or  256  squares  in  all. 
Instead  of  going  over  the  squares  in  rows  of  four,  a 
whole  set  of  sixteen  can  easily  be  counted  at  one  time. 
A  movable  stage  greatly  facilitates  the  enumeration. 

One  should  note  on  a  piece  of  paper  the  number 


CoUNriNG    THE    LEUCOCYTES.  1 87 

of  leucocytes  witli  multipartite  and  with  rounded  nuclei 
respectively  in  each  set  of  sixteen  squares.  In  this 
way  one  gets  the  proportion  of  each  variety  present, 
and  by  adding  them  together  the  total  number  of 
white  corpuscles  is  obtained.  The  calculation  is  made 
in  the  same  way  as  that  of  the  red  corpuscles,  it 
being  borne  in  mind  that  each  of  the  256  squares 
counted  represents  ^oVo  cmm,  of  diluted  blood,  and 
that  the  dilution  is  much  less  than  in  the  enumera- 
tion of  the  reds  (1  in  10,  or  1  in  20).  For  example, 
if  there  be  twenty-five  leucocytes  in  the  256  squares, 
this  represents  an  average  of  -^-^-^  per  square,  or 
2-^x  4,000  per  cmm.  of  diluted  blood,  or  7,182  per 
cmm.  of  pure  blood  if  the  dilution  is  1  in  10.  This 
is  about  the  normal  number. 

In  leucocythaemia,  where  a  very  large  excess  of 
leucocytes  is  present,  one  can  easily  count  the  red  and 
the  white  cells  in  the  same  drop.  For  this  purpose  a 
3  per  cent,  solution  of  common  salt  just  coloured  with 
gentian  violet  is  to  be  preferred  for  diluting  the  blood. 
This  stains  the  nuclei  of  the  whites,  and  at  the  same 
time  preserves  the  reds.  The  dilution  and  calculation 
are  the  same  as  for  the  red  cells. 

In  most  cases,  however,  it  is  not  easy  to  make  an 
accurate  estimation  of  the  leucocytes  by  means  of  an 
ordinary  hasmocytometer  such  as  that  of  Gowers. 
Should  its  use  be  unavoidable,  it  will  be  found  that 
the  easiest  way  to  pick  out  the  white  corpuscles  from 
the  mass  of  reds  which  tends  to  conceal  them  is  to 
raise  the  microscope  a  little  and  then  focus  slowly 
down  upon  the  field.  The  white  corpuscles,  being 
highly  refractile^  come  into  view  first  as  little  bright 
spots,  and  can  thus  be  more  easily  enumerated.  If 
Gowers'  instrument  is  used,  one  must  count  the  leu- 
cocytes in  fifty  squares,  and  multiply  the  result  by 
2,000.  This  gives  the  number  of  leucocytes  in  1  cmm. 
of  pure  blood. 


1 88  The  Blood. 

The  liiiniber  of  leucocytes  in  normal  blood  is 
about  7,000  per  cmm.,  or  1  to  700  reds.  The  number 
varies,  however,  within  considerable  limits  even  in 
health.  The  normal  proportion  of  leucocytes  with 
divided  nuclei  to  those  with  rounded  nuclei  is  about 
2  to  1. 

A  'physiological  leucocytosis,  in  which  the  small 
cells  with  rounded  nuclei  (lymphocytes)  are  both 
absolutely  and  relatively  increased,  occurs  in  infancy, 
during  pregnancy,  and  after  meals.  In  the  patlio- 
logical  leucocytosis,  met  with  in  fevers  and  other 
conditions,  the  increase  affects  chiefly  the  cells  with 
multipartite  nuclei,  and  these  may  come  to  be  ten  or 
more  times  as  numerous  as  the  others.  The  condition 
of  the  leucocytes  in  leucocythoimia  will  be  referred 
to  later. 

After  use,  the  diluting  pipettes  should  be 
thoroughly  cleaned.  A  little  trouble  in  this  is  repaid 
by  saving  of  time  and  annoyance  when  next  they 
come  to  be  used.  They  should  be  washed  out  (1) 
with  distilled  water,  (2)  with  absolute  alcohol,  and 
(3)  with  ether.  A  stream  of  air  should  then  be 
blown  through  till  one  is  sure  that  the  glass  ball  in 
the  chamber  moves  freely  without  tending  to  adhere 
to  the  sides.  To  save  time  in  these  manipulations, 
the  rubber  tube  may  be  taken  off  and  the  fluid  blown 
out  through  the  wide  end  of  the  pipette.  Coagulated 
blood  may  be  removed  from  the  capillary  tube  by 
means  of  a  horse-hair.  If  the  blood  adheres  firmly 
to  the  pipette,  it  may  be  removed  by  repeated  rinsing 
with  strong  alkali  or  acid,  or  it  may  even  require  to 
be  digested  away  with  pepsin. 

Estimation  of  Blood  Platelets. 

For  this  purpose  the  use  of  a  pipette  is  not  to  be 
recommended,  as  the  platelets  adhere  to  its  wall. 
One  also  requires  to  employ  a  diluting  fluid  of  a 
certain  degree  of  viscidity,  otherwise  the  platelets  are 


Estimation  of  Platelets.  189 

apt  to  run  into  groups.  The  best  method  of  pro- 
cedure is  as  follows  : — ■ 

Place  upon  a  slide  a  drop  of  a  mixture  of  equal 
parts  of  glycerine  which  has  been  saturated  with  dahlia 
and  2  per  cent,  salt  solution.  The  use  of  the  dahlia 
is  to  stain  the  platelets.  Touch  the  drop  of  blood 
with  this  mixture  and  cover.  Count  with  -J^  lens 
in  a  succession  of  fields,  (1)  the  platelets,  (2)  the  red 
corpuscles.  Continue  until  400  of  the  latter  have 
been  enumerated,  and  estimate  the  proportion  of 
platelets  to  red  corpuscles.  Normally  this  should  be 
as  1  :  8^.  By  then  making  an  estimation  of  the  reds 
in  the  ordinary  way,  one  arrives  at  the  number  of 
platelets  per  cmm.  Normally  this  is  about  640,000. 
Variations  in  their  number  are  not  yet  of  any  known 
clinical  significance. 

Two  precautions  are  necessary  in  making  the  above 
estimation  :  (1)  To  avoid  squeezing  the  blood  out  of 
the  puncture,  and  (2)  to  reject  any  preparation  in 
which  the  platelets  are  found  to  have  run  together 
into  clumps. 

The  estimation  of  the  amount  of  hsemo- 
gClohin  in  the  blood  may  be  accomplished  by  means 
of  either  v.  Fleischl's  hsemometer  or  Gowers'  hsemo- 
globinometer.* 

Von  Fleischl's  haemometer. — (Fig.  59).  The 
instrument  consists  of  a  stage,  resembling  that  of  a 
microscope,  with  an  aperture  in  the  centre.  Into  this 
aperture  there  fits  a  short  cylinder  (g)  with  a  glass 
floor.  The  cylinder  is  divided  into  two  compart- 
ments (a  and  (X )  by  a  vertical  partition.  Below  the 
stage  there  is  a  frame  carrying  a  wedge-shaped  piece 
of  coloured  glass  (k),  which  lies  opposite  the  bottom 

*  Dr.  George  Oliver  has  also  invented  a  new  form  of  hsemo- 
globinometer  which  gives  very  accurate  results  and  is  not  difficult 
to  use.  It  is  supplied,  along  with  full  directions,  by  the  Tintometer 
Co.  {vide  footnote,  p,  181). 


1 90 


The  Blood. 


of  one  half  of  the  cylinder  and  can  be  moved  with  a 
screw  so  that  any  thickness  of  the  wedge  can  be 
brought  below  the  cylinder.  Light  from  a  lamp 
(daylight  will  not  do)  is  reflected  into  the  bottom  of 
the  cylinder  by  means  of  a  white  disc  (s).     A  small 


Fig.  59. — "Von  Fleischl's  Hsemonieter. 

a',  compartment  above  tinted  wedge  ;    a,  compartment  for  blood ;  Ky  wedge 

turned  by  T;  P,  scale ;  G,  cylinder ;  M,  indicator ;  S,  disc ;  B,  screw  for 

adjusting  scale. 

capillary  tube  attached  to  a  wire  is  supplied  with  the 
instrument. 

Method  of  use.  Fill  one  compartment  (a)  about  a 
quarter  full  of  distilled  water.  See  that  the  capillary 
tube  is  quite  clean  and  dry.  To  ensure  this  one  may, 
if  necessary,  pass  through  it  a  threaded  needle,  the 
thread  being  soaked  in  alcohol.  Prick  the  lobe  of  the 
ear  and  insert  one  end  of  the  tube  sideways  into  the 
drop  of  blood.     The  tube  fills  itself  and  must  then  be 


Estimation  of  Hemoglobin.  191 

wiped  on  the  outside  so  that  no  blood  adheres  to  it. 
Plunge  the  tube  into  the  compartment  containing  dis- 
tilled water  and  shake  it  about  by  means  of  the  wire 
handle  till  all  the  blood  is  washed  out.  If  necessary, 
one  may  aid  this  by  forcing  water  through  the  tube 
from  a  dropping  pipette.  The  mixing  of  the  blood 
^Yith.  the  distilled  water  may  be  completed  with  the 
aid  of  the  wire  handle  of  the  tube,  care  being  taken 
that  no  blood  is  allowed  to  lurk  in  the  corners.  One 
now  fills  up  the  rest  of  this  compartment  and  the 
whole  of  the  other  with  distilled  water  from  a  dropper. 
All  daylight  is  now  excluded,  and  then,  looking  down 
upon  the  cylinder,  one  turns  the  screw  until  a  sufficient 
thickness  of  the  coloured  wedge  has  been  brought 
under  the  other  half  of  the  cylinder  to  match  exactly 
the  tint  of  the  blood.  One  then  reads  the  figure  on  the 
scale  (p)^  and  this  gives  the  percentage  of  hgemoglobin. 
The  instrument  is  so  constructed  that  when  the  screw 
is  opposite  the  mark  100  a  sufficient  thickness  of  the 
coloured  wedge  has  been  introduced  to  match  exactly 
the  colour  produced  in  the  other  half  of  the  cylinder 
by  the  amount  of  blood  which  the  capillary  tube  takes 
up,  provided  the  blood  contains  a  normal  amount  of 
haemoglobin.  To  facilitate  accurate  matching  of  the 
two  halves  of  the  cylinder,  the  following  precautions 
are  necessary  (Cabot) : — 

1. — Use  very  little  light.  The  less  the  percentage 
of  haemoglobin  the  less  light  one  should  use. 

2.  Look  at  the  two  halves  of  the  cylinder  through 
a  tube  made  of  a  roll  of  black  paper. 

3.  Do  not  sit  opposite  the  light  as  one  does  when 
using  a  microscope,  but  sit  at  one  side  of  the  instru- 
ment The  light  from  the  two  halves  of  the  cylinder 
then  falls  on  the  right  and  left  halves  of  the  retina,  not 
on  its  upper  and  lower  parts,  the  sensitiveness  of  which 
to  colours  is  unequal. 

4.  Use   one  eye   and   only  look    for  a   very   few 


192  The  Blood. 

seconds  at  a  time,  since  the  colour  sense  soon  gets 
fatigued. 

5.  Move  the  screw  with  short  quick  turns,  not 
gradually.  Sudden  changes  in  tint  are  more  easily 
appreciated  than  those  brought  about  gradually. 

Oouers'  hsemoglobinonieter.  —  Place  a 
couple  of  drops  or  so  of  distilled  water  in  the  little 
graduated  test  tube  supplied  with  the  instrument.  Get 
a  large  drop  of  blood  from  the  ear,  and  fill  the  pipette 
with  it  up  to  the  mark.  Then  dip  the  end  of  the  pip- 
ette into  the  distilled  water  in  the  tube  and  gently 
blow  out  the  contained  blood.  Mix  and  go  on  adding 
water  drop  by  drop,  comparing  the  colour  from  time  to 
time  with  that  of  the  standard  tube.  The  latter  is 
filled  with  prepared  blood,  and  represents  the  colour  of 
blood  which  contains  a  normal  amount  of  haemoglobin 
when  diluted  in  the  proportions  effected  by  the  instru- 
ment. The  comparison  should  be  made  both  by  trans- 
mitted light,  care  being  taken  to  hold  both  tubes  level 
with  the  eye,  and  also  by  reflected  light,  the  tubes 
being  held  side  by  side  against  a  sheet  of  paper. 
Good  daylight  is  indispensable.  Stop  adding  water 
when  the  tint  in  the  two  is  the  same,  and  read  off  the 
level  at  which  the  mixture  stands  in  the  graduated 
tube.  If  this  be  at  (say)  60,  then  the  blood  contains 
60  per  cent,  of  haemoglobin. 

We  are  inclined  to  think  that  Gowers'  instrument 
is  rather  over-standardised.  In  many  healthy  people 
the  proportion  of  haemoglobin  falls  short  of  100  per  cent, 
when  measured  by  it.  In  a  few  adults,  however, 
the  amount  rises  even  above  this,  and  it  must  also  be  re- 
membered that  the  amount  of  haemoglobin  in  the  blood 
at  birth  is  very  high — frequently  above  100  per  cent. 

In  all  forms  of  anaemia  the  percentage  is  dimin- 
ished, notably  in  chlorosis. 

One  can  also  state  the  percentage  of  haemoglobin  in 
terms  of  the  amount  contained  in  each  corpuscle.    Thus, 


Microscopical  Examination.  193 

if  the  number  of  red  cells  be  20  per  cent,  of  the 
normal  and  the  ha3moglobin  10  per  cent.,  then  the 
h{\3moglobin  value  of  each  corpuscle  is  \%  or  \  normal, 
Tlie  importance  of  this  method  of  expressing  the  facts 
is  seen  when  one  recollects  that  the  total  amount  of 
haemoglobin  in  the  blood  may  be  diminished  while 
the  amount  in  each  corpuscle  is  really  above  the 
normal.     This  happens  in  some  forms  of  ansemia. 

The  last  point  to  be  remembered  in  making  all 
blood  estimations  is  that,  as  far  as  possible,  all  observa- 
tions on  the  same  individual  should  be  carried  out 
under  the  same  conditions  as  regards  time  of  day, 
taking  of  food,  etc.  This  is  important,  as  it  is  found 
that  the  composition  of  the  blood  is  temporarily  altered 
by  the  taking  of  food,  or  by  the  occurrence  of  profuse 
sweating,  diarrhoea,  etc. 

Microscopical   Examination   of   Blood. 

Blood  may  be  examined  (1)  fresh,  (2)  fixed  but 
unstained,  (3)  stained. 

1.  Blood  examined  fresh. — A  drop  of  blood 
is  transferred  from  the  ear  to  a  slide,  covered,  and 
examined  at  once. 

In  the  case  of  normal  blood,  the  red  corpuscles 
will  be  observed  to  arrange  themselves  in  rouleaux 
as  one  watches,  clear  spaces  being  left  between  in 
which  the  white  cells  and  little  clumps  of  aggregated 
platelets  may  be  seen.  Any  abnormality  in  the 
shape  of  the  red  cells  or  in  the  formation  of  rouleaux 
should  be  noted.  It  can  also  be  seen  whether  any 
large  excess  of  white  corpuscles  is  present.  The 
presence  of  abnormal  elements  should  be  noted. 
Amongst  these  are  abnormal  varieties  of  white  cells, 
although  these  are  more  easily  recognised  in  stained 
specimens. 

The  best  method  of  staining  preparations  of  fresh 
blood  is  to  dilute  the  drop  with  an  equal  quantity  of 

N 


T94 


The  Blood. 


\  per  cent,  salt  solution  to  which  a  little  methyl 
violet  has  been  added.  This  stains  the  nuclei  of  the 
leucocytes  and  the  blood  plates.  It  also  brings  out 
nucleated  red  corpuscles  if  these  are  present. 

Sometimes   particles   of  pigment    can    be  noticed 


Fig.  00. — Filaria  nocturna  ;   x  160.     {After  Patrick  Manson.) 


amongst  the  corpuscles.  This  is  the  condition  known 
as  nialaiieeiiiia.  It  is  found  occasionally  in  chronic 
malaria. 

The  spirilliiiii  of  relapsing  fever  can  be 
recognised  by  this  method,  and  also  the  lllariae 
«>aiig'uJiii!s>  lioiiiiiiis.  The  latter  can  be  seen, 
with  a  low  power,  moving  about  among  the  red  cells. 


Microscopical  Examination.  195 

They  average  about  -/-.-  in.  in  length,  and  are  about 
as  broad  as  a  red  blood  corpuscle  (Figs.  60,  61). 
They  remain  alive  for  a  surprisingly  long  time  even 
at  ordinary  temperatures,  especially  if  the  prepara- 
tion is  kept  from  drying  by  being  sealed  with  a  little 
vaseline.  The  following  is  the  method  recommended 
by  Manson  as  best  suited  for  their  demonstration  : — 


Fig.  61. — Embryos  of  filaria  noctuiua  in  Llood  ;    x  50.    (From  an  origina 
m  icrophotograph. ) 

Spread  out  a  thick  drop  of  blood  on  a  slide  by 
means  of  a  needle,  and  allow  it  to  dry.  It  may  then 
be  preserved  indefinitely.  When  the  parasites  are 
to  be  demonstrated,  immerse  the  slide  in  a  solution 
of  one  drop  of  saturated  alcoholic  fuchsin  in  1  oz. 
of  water.  Stain  in  this  for  one  or  two  hours.  If, 
on  examining  the  film,  it  is  found  that  the  blood 
is    very    deeply    stained,    one    must    decolorise    by 


196  The  Blood. 

means  of  dilute  acetic  acid  (four  drops  of  acetic  acid 
to  1  oz.  of  water).  The  specimen  may  Ije 
examined  either  wet  or  dry,  and  with  or  without 
a  cover.  On  searching  it  with  a  low  power,  the 
filarise  will  be  recognised  by  their  being  very  deeply 
stained.  The  preparation  is  apt  to  fade  after  a  few 
days. 

A  more  rapid  result  is  obtained  by  staining  the 
film  for  half  a  minute  in  a  2  per  cent,  solution  of 
methylen  blue.  It  is  then  decolorised  a  little  with 
dilute  acetic  acid  as  above  described,  and  examined 
with  a  low  power  while  wet.  If  a  permanent  prepara- 
tion is  desired,  the  film  is  allowed  to  dry  and  a  drop 
of  balsam  and  a  cover  glass  applied. 

2.  Blood  cells  fixed  but  unstained. — 
This  is  the  best  method  for  studying  changes  of 
shape  and  size  in  the  cells  ;  2  per  cent,  osmic  acid  is 
the  most  useful  fixative.  Place  a  drop  of  it  on 
the  finger  or  lobe  of  the  ear,  and  prick  the  skin 
through  it.  The  blood  is  fixed  as  soon  as  it  exudes, 
and  the  mixed  drop  may  be  examined  immediately. 
The  addition  of  a  little  methyl  green  to  the  osmic 
acid  helps  to  bring  out  the  nuclei  of  the  leuco- 
cytes. Permanent  preparations  may  be  obtained 
by  running  in  a  drop  of  glycerine  under  the  cover 
glass. 

This  method  shows  very  well  the  blood  plates 
and  the  size  and  shape  of  the  red  corpuscles.  Nor- 
mally, of  course,  the  latter  are  all  disc-shaped  and 
practically  uniform  in  size.  In  some  diseased  con- 
ditions, however,  this  ceases  to  hold  good.  Thus 
there  may  be  a  number  of  red  corpuscles  present 
which  are  decidedly  smaller  than  normal  (microcytes), 
whilst  others,  again,  may  be  considerably  above  the 
average  size  (megalocytes).  Or  the  red  corpuscles 
may  be  distorted — spindle-shaped,  indented,  budded, 
etc.      This  is  known  as  'poikilocytosis.      It  is  apt   to 


Microscopical  Examination,  197 

occur  in  some  forms  of  anaemia,  especially  in  per- 
nicious antemia. 

3.    £xaiiiiiiattoii     of     blood     in     liliii<^. — 

Films  may  be  made  either  on  slides  or  on  cover 
glasses.  The  former  have  the  advantage  of  being 
more  easily  manipulated.  To  make  a  good  film,  it 
is  important  that  the  slides  or  covers  should  Ije  free 
from  grease.  Slides  should  Ije  washed  in  ammonia, 
rinsed  in  ether,  and  then  rubbed  with  a  clean  silk 
handkerchief  or  piece  of  old  cotton.  Cover  slips 
should  be  immersed  for  a  few  hours  in  strong- 
nitric  acid,  washed  in  w^ater,  and  then  in  alcohol 
and  ether.  Simple  boiling  wdth  soap  and  water  is  also 
an  efficient  means  of  cleaning  them.  They  should  be 
preserved  in  alcohol  to  which  a  little  ammonia  has 
been  added,  and  when  wanted  should  be  rubbed  wnth 
a  piece  of  clean  silk. 

Ho\*^  to  make  films.— (1)  On  cover  slips. 
Prepare  several  clean  cover  slips — preferably  square 
ones — and  prop  them  up  in  a  row  so  that  they  can 
be  easily  grasped  by  their  edges.  Prick  the  ear. 
Touch  the  apex  of  the  drop  of  blood  with  the  centre 
of  a  cover  slip,  care  being  taken  not  to  touch  the 
skin.  Drop  another  cover  slip  on  the  top  of  the 
drop  of  blood  in  such  a  way  that  the  corners  of 
the  two  cover  slips  do  not  coincide  but  are  placed 
diagonally  to  one  another.  This  makes  it  more  easy 
to  grasp  them  separately.  The  drop  of  blood  spreads 
out  at  once  into  a  film,  and  w^henever  it  has  spread 
slide  the  cover  slips  apart  without  squeezing  them, 

(2)  On  slides.  Tw^o  slides  are  takeu,  one  of 
which  should  have  a  smooth  ground  edge  at  least  at 
one  end.  The  majority  of  the  better  variety  of 
microscope  slides  do  quite  well.  A  small  drop  of 
blood  is  transferred  to  the  surface  of  the  other  slide 
at  a  distance  of  about  i  in.  from  one  end. 
The    smooth    edsje    of    the  other   slide  is    then    used 


198 


The  Blood. 


to  spread  out  the  drop  by  pushing  it  over  the  latter 
like  a  plane  (Fig.  62).  In  this  way  a  long  thin  film 
is  spread  out  on  the  sui-face  of  the  slide.  Only  one 
film  is  obtained  at  a  time  by  this  method,  but  it  is 
much  larger  than  those  which  are  made  on  cover 
glasses. 

We  are  indebted  to   Dr.  Patrick  Manson  for  the 


OP    or    BLOOD 


-^ 


riLM      OF     BLOOD 


SLIDE 


Fig.  62.— Diagram  showing  metliod  of  making  a  blood  film  by  means  of 

two  slides. 

description  of  a  very  simple  and  rapid  method  of 
making  films  upon  slides  : — Take  a  piece  of  gutta- 
percha tissue  about  2  in.  long  and  1  in.  broad.  Fold 
it  slightly  along  its  long  axis  so  that  one  side  becomes 
somewhat  convex,  the  other  concave.  Pass  one  end 
of  the  convex  surface  lightly  across  the  top  of  the 
drop  of  blood  and  immediately  lay  it  flat  on  the  slide 
near  one  end.  Wait  for  a  moment  till  the  blood  has 
had  time  to  spread  itself  out  between  the  slide  and 
the  gutta-percha  tissue,  then  draw  the  latter  lightly 
along  the  surface  of  the  slide.  A  thin  film  of  blood 
is  thus  spread  out.  A  large  series  of  very  good  films 
can  be  prepared  by  this  method  in  a  few  minutes,  the 
gutta-percha  tissue  being  reapplied  to  the  drop  of 
blood  after  every  second  film  has  been  made. 

Fixation  of  the  film. — (1)  By  drying.     Cover 


Microscopical  Examination.  199 

glass  films  may  be  allowed  to  dry  in  the  air.  Waving 
the  slip  about  hastens  the  process.  They  should 
then  be  stained  for  half  a  minute  in  a  saturated 
solution  of  methylen  blue  in  absolute  alcohol,  washed 
in  water  to  remove  superfluous  stain,  allowed  to  dry, 
and  mounted  in  balsam.  This  method  does  fairly 
well  for  rouofh  clinical  examination.  To  oet  better 
results,  one  may  use  Ehrlicli's  fixation  method.  The 
dried  slide  or  cover  glass  films  are  placed  in  an  oven, 
which  is  slowly  heated  up  to  115°  0.  This  takes 
about  half  an  hour.  They  are  left  at  this  tem- 
perature for  ten  minutes^  and  the  flame  is  then 
extinguished.  After  another  ten  minutes  they  are 
removed,  and  are  now  ready  for  staining.  AVe  have 
found  that  mereh"  leaving  the  films  overnight  in 
an  ordinary  paraffin  oven  gives  almost  equally  good 
results  and  is  less  troublesome.  The  dried  films  may 
be  kept  away  from  dust  till  a  batch  has  been  col- 
lected ;  these  are  then  placed  in  a  box  in  the  oven 
and  left  overnight. 

Very  good  results  can  also  be  obtained  by  heating 
the  films  on  a  strip  of  metal  at  a  temperature  of 
100'  C.  for  a  quarter  of  an  hour.  One  proceeds 
thus  : — A  strip  of  clean  metal,  preferably  copper, 
about  1  ft.  long  and  3  in.  broad,  and  supported  on 
a  tripod,  is  heated  in  its  centre  by  means  of  a 
Bunsen  or  spirit  lamp.  When  the  centre  has 
attained  a  fairly  constant  degree  of  heat,  one  deposits 
drops  of  water  in  succession  from  near  the  centre 
outwards.  The  point  at  which  a  drop  j'ust  boils  is  of 
approximately  the  right  temperature.  The  films  are 
then  laid  on  the  metal  at  that  spot,  face  downwards, 
and  left  for  a  quarter  of  an  hour.  They  are  then 
allowed  to  cool,  and  are  ready  for  staining. 

(2)  By  corrosive  sublimo.te.  —  One  requires  a 
saturated  solution  of  corrosive  sublimate  in  normal 
salt  solution.     Be  sure  that  the  solution  is  saturated 


^6o  The  Blood, 

at  the  boiling  point,  so  that  crystals  separate  out  on 
cooling.  The  films  are  placed  in  this  while  still 
moist.  Cover  glass  films  are  floated  on  the  surface 
of  the  solution.  Slide  films  are  best  placed  standing 
back  to  back  in  a  wide-necked  bottle  filled  with 
it.  Leave  the  films  for  at  least  half  an  hour  (longer 
does  no  harm).  Wash  them  thoroughly  in  normal 
salt  solution,  and  then  in  successive  strengths  of 
alcohol  to  which  a  little  salt  has  been  added.  (For 
clinical  work  washing  in  alcohol  may  be  omitted.) 
The  removal  of  the  corrosive  is  facilitated  by  adding* 
a  drop  or  two  of  iodine  to  the  50  per  cent,  alcohol. 
The  films  are  then  ready  for  staining. 

(3)  The  following  method  has  been  described 
by  Gulland  as  very  simple  and  trustworthy.  Films 
are  made  in  the  usual  way.  They  are  placed  at  once 
in  a  mixture  of  the  following  composition  : — 

Saturated  solution  of  eosin  in  absolute 

alcohol  ...  ...  ...  ...   25  cc. 

Pure  ether       ...  ...  ...  ...   25  cc. 

-  Solution   of    corrosive    sublimate    in 

absolute  alcohol  (2  grms.  in  10  cc.)     5  drops. 

Some  of  this  fluid  is  placed  in  a  flat  dish  and 
the  cover  slips  are  floated  on  it,  wet  side  downwards ; 
5  cc.  to  10  cc.  is  suflicient  for  four  cover  glasses. 

Films  on  slides  may  be  plunged  into  a  wide- 
necked  bottle  containing  the  mixture.  The  same 
quantity  of  the  fixing  solution  may  be  used  several 
times  if  it  be  covered  up  so  as  to  prevent  evapora- 
tion. Fixation  will  be  complete  in  three  minutes, 
but  it  will  do  no  harm  to  leave  the  films  in  the 
solution  for  twenty-four  hours.  Pick  out  the  cover 
glasses  with  forceps,  and  wash  them  thoroughly  in 
a  small  basin  of  water,  waving  them  to  and  fro. 
Stain  for  one  minute  in  a  satui-ated  watery  solution 
of  methylen  blue.     Wash  again.     Dehydrate  rapidly 


Microscopical  Examination.  201 

with  absolute  alcohol.  Clear  in  xylol,  and  mount  in 
xylol  balsam. 

Red  corpuscles  are  stained  pink,  all  nuclei  deep 
blue,  the  blood-plates  a  fainter  blue.  The  bodies  of 
the  leucocytes  are  in  various  shades  of  pink,  the 
eosinophile  and  basophile  granules  being  well  brought 
out.      Organisms  are  also  well  stained. 

Pus,  sputum,  etc.,  may  also  be  examined  by  the 
above  method,  but  the  fixation  time  for  these  should 
be  longer. 

How  to  §taiii  tlie  liliii!!i. 

One  must  employ  a  "  nuclear  stain  "  to  pick  out 
the  nuclei,  and  some  "  contrast  stain "  to  stain  the 
protoplasm.  It  must  be  remembered  also  that  the 
granules  contained  in  the  protoplasm  of  the  different 
varieties  of  leucocytes  stain  in  various  ways.  Some 
have  an  afl&nity  for  "  acid,"  and  others  for  "basic," 
dyes.  An  "  acid  dye "  is  a  salt  the  acid  part  of 
which  has  staining  power.  In  the  case  of  a  "  basic 
dye,"  it  is  to  the  base  that  the  staining  power  of  the 
compound  is  due.  The  most  commonly  used  acid 
dyes  areeosin,  rubin — i.e.  acidfuchsin — and  aurantia  j 
good  examples  of  basic  dyes  are  found  in  methylen 
blue,  gentian  violet,  and  safranin.  The  following 
combinations  of  stains  will  be  found  to  give  very 
good  results  for  all  ordinary  purposes  : — 

1.  Methylen  blue  and  eosin. — Stain  the  film  for  a 
quarter  of  a  minute  in  moderately  strong  watery  eosin, 
or  for  ten  minutes  in  eosin  and  glycerine.  Wash  in 
water.  Stain  for  two  or  three  minutes  in  LofHer's 
methylen  blue  (Appendix,  22),  wash  in  water,  dry  and 
mount  in  balsam,  or  dehydrate  with  absolute  alcohol, 
clear  in  xylol,  and  mount  in  balsam.  All  nuclei  are 
stained  blue  by  this  method.  The  red  blood  corpuscles 
are  pink.     All  oxyphil e  cells  stain  strongly  pink. 

2.  Ehrliclis  triple  stain  of  aurantia,  acid  fuchsin, 
and  methyl  green  (Appendix,  25).     Stain  for  one  to 


2  02  The  Blood. 

five  minutes  in  a  strong  solution.  Wash,  allow  to 
dry,  mount  in  balsam.  Nuclei  are  stained  a  greenish 
blue ;  oxyphile  granules  are  red.  The  so-called 
neutrophiles  are  purple.  Basophile  granules  are 
unstained. 

3.  Hcematoxylin  and  eosin.  Stain  for  half  a  minute 
in  Delafield's  hsematoxylin.  Wash  in  distilled  water 
and  then  in  a  bowl  of  water  to  which  a  pinch  of  lithia 
carbonate,  or  carbonate  of  soda,  has  been  added. 
Then  place  in  saturated  watery  eosin  for  ten  seconds. 
Wash,  dry,  mount  in  balsam. 

All  nuclei  are  stained  bine,  red  corpuscles  pink, 
and  eosinophile  cells  are  well  brought  out. 

If  cover  slip  films  are  used  they  should  be  floated 
face  downwards  on  the  stain.  Slide  films  may  be 
plunged  into  a  wide-necked  bottle  containing  the 
stain,  and  left  there  the  requisite  time.  The  bottle 
should  be  deep  enough  to  admit  the  entire 
slide,  and  a  glass  cover  may  then  be  placed  on 
the  top. 

Examination  of  the  tilm. 

In  a  good  film  the  corpuscles  should  be  spread  out 
evenly,  no  rouleaux  being  seen.  Even  with  the  low 
power  the  white  cells  can  be  recognised  by  their 
stained  nuclei,  and  some  idea  can  be  gained  of  their 
relative  numbers.  For  the  minute  examination  of 
the  white  cells  a  high  power,  and  preferably  an 
immersion  lens,  is  requisite.  It  must  first  of  all  be 
remembered  that  the  following  are  the  varieties  of 
leucocytes  found  in  normal  blood  (Plate  IV.,  Fig.  1), 
with  their  relative  proportions  : — 

1.  Leucocytes  with  multipartite  nucleus 

and  very  fine  oxyphile  granules      ...  ...      60-75% 

2.  Leucocytes,  with  round  or  branched 
nucleus  and  coarse  oxyphile  granules         ...  2-4% 

3.  Small      leucocytes      with      rounded 
nucleus  and  no  granules  (lymphocytes)      ...      20-30% 


I'll..     1.     CELLS    L»i-'    NUUMAL    JJLOOD. 


a.  Fiiiely-grauular  (iosiiioiiliilc;  leucocyte. 

'/.   Coar.sely-graiiular  cosiiiopliilr'  Idicocyte. 

c.   Lyiriphocyte. 

(.1.  Hyaline   leucocyte,   witli   line  auioi'iihous 
points  of  Ijasoithile  substance. 

e.  Finely-granular  basopliile  leucocyte- 

/.   Rod  Ijlood  corpuscle. 


Fro.    2.— CELLS   FROM    THE    BLOOD    IX    SPLFXO-MVELOGEXOUS 

LEUCyEillA. 
«.  Myelocyte  ;  a',  with  mixed 
granulation  ;  a" ,  Avlth 
double  nuclei  ;  a'",  mye- 
locyte undergoing  mi- 
tosis. 
h.  Normal  coarsely-granular 
cosinojjliile  leucocyte. 

c.  Normal       finely  -  granular 

eosinoijliile     leucocyte  ; 
c\  non-granular. 

d.  Atyjiical  coarsely-granular 

eosinopliile  leucocyte.  l 

K.  Lyijiphocyte,  with  fine  baso- 
pldJe  amorphous  points. 

/■  Xoi'inal  finely  -  granulai' 
basophile  leucocyte. 

(J.  Atypical  liasojihile  myelo- 
cyte. 

h.  Nucleated  red  blood  cor- 
Ijuscle ;  fi,  undergoing 
mitosis. 

/.    Hyaline  leucocyte,  with  fine  basophile  amorplions  points. 


Fig.  8.— CELLS    FROM    THE    liU)U\}    IX    LVMPHOCYTH^MIA. 

^-=^  -  "  (X.  Lyinphocyte,  with  fine  basopliile 

amorphous  ])Oints. 
/;.  Hyaline  leucocyte,  with  basophile 

amorjihous  points. 
'/.  Atypical  basophile  leucocytes. 
e.    N^orinal   finely-granular   liasophiie 

leucocyte. 
/.    X^ornial  finely-granular  eosinophile 

leucocyte. 
(J.  Xormal   coarsely-granular  eosino- 

idiile  leucocyte. 
h.  Xormal  red  blood  corpuscle. 
/.    Xucleated  red  blood  corpuscle. 

PLATE    IV. 

(From  an.  Original  Dividing  liij  Jjr.  Jlabert  J.  M.  JJadaiiMn.) 

[To  face  p.  20.3. 


Microscopical  Examination.  203 

4,  Large  leucocytes  with  rotinded 
nucleus  and  no  granules  ("hyaline" 
corpuscles).,.  ...  ...  ...  ...  6°/^ 

5.  Leucocytes    with    lobed    nuclei  and 

small  basophile  granules      ...  ...  ...  l-^V^ 

The  alterations  which  occur  in  the  relative  pro- 
portions of  these  in  leucocytosis  have  been  mentioned 
above  (p.  188). 

In  the  lyini:>liatic  (or  lymphocytic)  form  of 
leiicocytliceiiiia  an  enormous  increase  occurs  in 
the  number  of  the  lymphocytes  (Plate  IV.,  Fig.  3). 

In  the  spleno-myelogenous  form  of  the  disease  the 
coarsely  oxyphile  (eosinophile)  cells  are  both  rela- 
tively and  absolutely  increased,  and  in  addition  one 
meets  with  abnormal  cells,  probably  derived  from  the 
bone-marrow,  and  known  as  myelocytes  (Plate  IV., 
Fig.  2).  These  are  of  a  large  size,  and  contain  one 
excentrically-placed  nucleus,  which  stains  rather 
faintly.  They  contain  small  granules,  but  it  is 
doubtful  whether  these  are  oxyphile  or  neutrophile. 
The  myelocytes  may  amount  to  50  per  cent,  of  all 
the  corpuscles  present. 

In  lyrtvpliadenoma  the  ordinary  leucocytes  with 
multipartite  nucleus  are  slightly  increased.  The 
coarsely  oxyphile  cells  are  not  at  all  increased,  and 
there  are  no  abnormal  cells  present. 

In  examining  blood  films  one  sometimes  encoun- 
ters nucleated  red  corpuscles.  These  are  normal 
constituents  of  the  blood  for  the  first  few  days  after 
birth,  and  are  present  abnormally  in  all  extreme 
cases  of  diminution  of  the  red  cells,  notably  in  leuco- 
cytluemia  and  pernicious  anaemia.  They  can  be 
distinguished  from  lymphocytes  (for  wdiich  at  the  first 
glance  they  are  apt  to  be  mistaken)  (1)  by  the  more 
homogeneous  staining  of  the  nucleus ',  (2)  by  the 
presence  round  the  nucleus  of  a  much  wider  rim 
of  protoplasm   than   a    lymphocyte    possesses,    which 


204  The  Blood. 

stains  very  much  more  deeply  than  that  of  a  lympho- 
cyte, and  with  high  powers  one  can  often  see  a  clear 
space  between  the  nucleus  and  the  surrounding  rim 
of  protoplasm  ;  (3)  by  the  fact  that  the  contour  of  a 
nucleated  red  corpuscle  is  smooth,  while  that  of  a 
lymphocyte  is  usually  more  or  less  irregular  {see  Plate 
IV.,  Figs.  2,  3). 

It  should  be  remembered  that  nucleated  red 
corpuscles  are  often  much  larger  than  the  ordinary 
kind. 

Parasites  in  the  blood. — We  have  already 
described  the  way  to  look  for  filarise  in  the  blood 
(p.  195).  Of  this  parasite  there  are  several  species 
which  are  the  embryos  of  corresponding  parental 
forms.  The  embryos  live  free  in  the  blood ;  the 
parental  forms  are  found  in  the  tissues  and  lymphatics. 
In  one  species  the  embryos  are  present  in  the  blood 
during  the  night  only  {F.  nocturna),  in  another  only 
by  day  {^F.  diurna).  In  yet  another  form  (i^.  perstans) 
they  are  always  present.  The  blood  in  suspected 
cases  should  therefore  be  examined  both  during  the 
day  and  during  the  night.  For  the  diagnosis  of 
the  different  species  special  works  must  be  consulted, 
but  the  chief  points  to  attend  to  are  :  (1)  The  time 
when  the  parasites  are  present  in  the  blood ;  (2)  the 
nature  of  their  movements  ;  (3)  whether  or  not  they 
possess  a  sheath ;  (4)  the  shape  and  character  of  their 
extremities. 

To  recognise  the  parasite  of  malaria,  proceed 
as  follows  : — 

Prepare  some  perfectly  clean  and  very  thin  cover 
slips,  and  remove  all  traces  of  grease  in  the  manner 
already  described  (p.  197).  Cleanse  the  skin  of  the 
tinger-tip  or  ear  with  soap  and  water  and  then  with 
alcohol  and  ether.  Make  a  small  2yrick  in  the  skin. 
Wipe  away  the  first  drop  of  blood,  leaving  a  perfectly 
dry  surface,  so  that  subsequent  drops  will  not  run. 


Fig.  1. 


tiffif 


'^•^ 


Fig.  2. 


Fig.  3. 


Fig.  4. 


Fig.  5. 


PLATE    v.— THE    BLOOD    IN    MALAEIA.      Showing    dilTeront  forms    and 
stages  of  development  of  the  parasite.     {AJter  'Thayer  and  Ilcwctson.) 

Fig.  1.— The  parasite  of  tertian  fever. 

Fig.  2. —The  X)arasite  of  quartan  fever. 

Fig.  3.— The  parasite  of  festivo-autuninal  fever. 

Fig.  4. — Creseentic  and  oval  bodies. 

Fig.  5. — Flagellated  forms. 


[Tofare2->.  205. 


Microscopical  Examination.  ^  205 

Squeeze  out  a  tiny  dro[)  about  the  size  of  a  large 
piu's  head.  Touch  the  apex  of  this  drop  with  the 
centre  of  a  cover  glass,  and  immediately  drop  it,  face 
downwards,  on  a  perfectly  clean  slide.  Make  several 
such  preparations,  and  reject  all  those  in  which  rou- 
leaux are  present.  It  is  absolutely  essential  that  the 
red  corpuscles  should  lie  flat.  Examine  with  a 
J^  immersion  lens  and  rather  feeble  illumination. 
Look  in  the  red  corpuscles  for  the  presence  of  small 
black  specks,  often  rod-like  and  showing  slow  move- 
ments of  translation  (Plate  V.,  Figs.  1,  2).  These  are 
surrounded  by  clear  areas.  One  may  also  see  in  the 
centre  of  some  of  the  red  cells  clear  amoeboid  areas 
which  show  no  pigment  (Plate  Y.,  Figs.  1,  2).  Rosette 
forms  may  also  be  visible  (Plate  Y.,  Fig.  2).  These 
forms  of  the  parasite  are  always  present  in  cases  of 
malaria  which  have  not  had  quinine.  Other  varie- 
ties are  only  met  with  in  some  chronic  cases.  Of 
these  there  are  two   chief  forms  :  (1)  The  crescentic, 

(2)  the  flagellated  (Plate  Y.,  Figs.  4  and  5).  These  are 
easily  recognised.  The  crescentic  bodies  are  highly 
refractile,  rather  longer  than  a  red  blood  corpuscle 
and  about  2  ^n  in  diameter.  Particles  of  pigment  may 
be  recognised  in  the  parasite  and  also  in  some  of  the 
ordinary  leucocytes. 

The  examination  of  blood  for  the  malarial  parasite 
demands  some  care.  Manson  says  that  one  must 
devote  half  an  hour  to  the  examination  of  a  slide 
before  pronouncing  on  the  absence  of  parasites  in  it. 
The  quartan  form  of  the  parasite  (Plate  Y.,  Fig.  2) 
is  distinguished  from  the  tertian  (1)  by  being  smaller 
in  size,   (2)  by  its  pigment    granules    being    darker, 

(3)  by  its  showing  fewer  segmenting  forms. 

If  it  be  desired  to  stain  the  parasite,  one  should 
use  for  the  purpose  a  concentrated  solution  of  methylen 
blue  in  06  per  cent,  salt  solution.  A  tiny  drop  of 
this  is  placed   on   the  skin,  and    the  puncture   made 


2o6        ^  The  Blood. 

through  it.  The  mixed  drop  is  then  examined  as 
above.  The  parasite  stains  blue,  while  the  red  cells 
remain  uncoloured.  "^ 

To  get  'permanent  preparations  proceed  as  fol- 
lows : —  Stain  a  fixed  film  for  two  seconds  with  very 
dilute  eosin  (0"5  cc.  concentrated  alcoholic  eosin  to 
500  cc.  water),  wash,  pour  on  some  Loffler's  solution 
(Appendix,  22),  diluted  one  in  four  of  water.  Wash 
this  off  after  a  few  seconds,  allow  the  film  to  dry, 
and  mount  in  balsam. 

The  parasite  is  stained  blue  and  the  red  cells  pink. 

The  examination  of  the  blood  for  bacteria  is 
considered  in  Chapter  XIV. 

Carbonic  oxide  in  the  blood. — In  cases  of 
suspected  carbonic  oxide  poisoning,  the  presence  of 
the  gas  may  be  detected  by  spectroscopic  examination. 
Some  blood  is  obtained  by  the  application  of  a  cup- 
ping-glass and  is  freel}"^  diluted  with  distilled  water. 
The  solution  has  a  cherry-red  colour.  Place  some  of 
it  in  a  thin  flat  glass  tube,  and  examine  with  a  hand 
spectrum.  Direct  the  spectrum,  as  in  all  such  examina- 
tions, towards  a  white  cloud  and  not  towards  the  sun. 
Two  bands  (Fig.  63)  are  seen  (bands  of  carbonic  oxide 
haemoglobin)  occupying  very  much  the  position  of  the 
oxyhsemoglobin  bands.  They  are  distinguished  from 
the  latter  by  the  fact  that  addition  of  a  few  drops  of 
sulphide  of  ammonium  produces  no  alteration  in  them. 

Various  methods  have  been  proposed  for  the 
clinical  estimation  of  the  specific  gravity  of  the 
blood.     The  simplest  is  the  following  : — 

A  mixture  is  made  of  chloroform  and  benzol  in 
such  proportions  that  the  specific  gravity  of  the  fluid, 
as  taken  with  a  sensitive  urinometer,  is  1,060.  Some 
of  this  is  placed   in   a   tall  glass  vessel,  and  a   drop 

*  Patrick  Manson  has  described  a  special  method  by  which 
the  flagellated  form  of  the  parasite  can  be  successfully  stained 
{Brit.  Med.  Journal,  1897,  vol.  ii.,  p.  68). 


Chart  of  Specfra.  207 

Red         Orange  Yellow  Green  Blue  Violet 

"I 

B    C 


VII. 


VIII. 


Fig.  63.— Spectra  of  hfemoglobiu  and  its  derivatives. 

I.,  oxvhsEniogloTjin  ;  II.,  reduced  haemoglobin  ;  HI.,  carbonic  oxide  baenioglobin; 
IV.,  methairaoslobin  (in  acid  solutiont;  V.,  acid-b«raatin ;  VI.,  alkali- 
li;ematin  ;  VII.,  haeniochromogen  ;  VIII.,  Laematoporphyrin  (in  acid  soliuion) ; 
IX.,  liKiuatoporphyrin  (in  alkaline  soluiionj. 

of  blood  added  to  it  from  a  hsemocytometer  pipette. 
If  the  drop  remains  suspended  without  either  rising 
to  the  surface  or  sinking  to  the  Itottom,  the  spe- 
cific   gravity  of  the   blood    is   the    same    as    that    of 


2o8  The  Blood. 

the  mixture.  If  the  drop  floats,  add  benzol  out  of 
a  burette,  stirring  well  with  a  glass  rod,  until  the 
drop  remains  suspended.  If  it  sinks,  add  chloroform 
till  a  similar  result  is  attained.  Then  take  the  specific 
gravity  of  the  mixture  with  a  urinometer,  and  the 
result  will  give  the  specific  gravity  of  the  blood. 

The  normal  specific  gravity  of  blood  is  about 
1,060.  Variations  are  not  of  much  clinical  value. 
The  specific  gravity  is  always  in  proportion  to  the 
amount  of  haemoglobin — a  low  specific  gravity  means 
little  haemooflobin.  The  ratio  is  so  constant  that  one 
can  tell  the  percentage  of  haemoglobin  by  taking  the 
specific  gravity. 

The  clinical  estimation  of  the  albalinity  of  the 
1>lood  can  only  be  accomplished  by  the  use  of  rather 
elaborate  methods,  the  results  yielded  by  which  are 
not  of  sufficient  importance  to  justify  their  description 
in  a  work  such  as  this.* 

The  coagulability  of  the  hlood  can  be  esti- 
mated with  a  fair  degree  of  accuracy  by  means  of 
Wright's  coagulometer.t  The  instrument  consists  of 
a  series  of  fine  tubes  of  equal  calibre  which  are 
kept  at  a  uniform  temperature  by  being  placed  in 
a  jacket  surrounding  a  tin  of  water.  Blood  is  drawn 
into  each  of  the  tubes  at  definite  intervals,  and,  after 
the  lapse  of  varying  periods  of  time,  one  blows  down 
the  tubes  in  succession.  If  the  blood  can  no  longer 
be  blown  out,  coagulation  has  occurred.  The  interval 
between  the  filling  of  the  tube  and  the  occurrence 
of  coagulation  is  known  as  the  "  coagulation  time." 
At  a  temperature  of  18  "5°  C,  the  coagulation  time 
of  a  healthy  individual  is  about  four  minutes. 

*  For  a  discussion  of  the  methods  enii^loyed  in  the  clinical 
estimation  of  the  alkalinity  of  the  blood  and  the  results  which 
they  have  3delded,  see  a  paper  by  one  of  the  authors  (Dr.  Hutchi- 
son) in  the  Lancet,  March  7th,  1896. 

t  The  instrument  is  supplied,  along  with  full  directions  for  use, 
by  Dean,  73,  Hatton  Garden,  London,  E.G. 


209 


CHAPTER    Y. 

Respiratory  System. 

SECTION  I.— ANATOMY. 

(Plates  L,  II.,  Iir.) 

The  following  anatomical  facts  must  be  boi-ne  in 
mind  when  the  lungs  are  examined  : — 
1.    Borders  of  tlie  Iniig^s. 

Rig-lit  lung'. — The  anterior  border  passes  for- 
wards, downwards,  and  towards  the  middle  line  from 
the  apex,  which  lies  at  the  level  of  the  neck  of  the  first 
rib.  Behind  the  sternum,  at  the  level  of  the  second 
rib,  it  has  nearly  reached  the  middle  line,  and  passes 
directly  downwards  to  the  level  of  the  junction  of  the 
sixth  costal  cartilage  with  the  sternum,  where  it  turns 
rather  abruptly  to  the  right  to  pass  outwards  as  the 
lower  border.  The  lower  border  meets  the  right  para- 
sternal line  at  the  level  of  the  upper  border  of  the 
sixth  rib,  the  mammary  line  also  at  the  level  of  the 
sixth  rib,  the  axillary  lines  at  the  seventh  and  eighth 
ribs,  the  scapular  line  at  the  tenth  rib,  and  at  the 
side  of  the  vertebral  column  reaches  as  far  as  the  tenth 
interspace  or  eleventh  rib. 

Left  lung. — From  the  apex  to  the  level  of  the 
fourth  costal  cartilage  the  anterior  border  passes  in  a 
direction  which  corresponds  with  that  of  the  right 
lung.  At  this  point  it  bends  rather  suddenly  out- 
wards, thereby  lea^^ng  part  of  the  anterior  surface 
of  the  heart  exposed,  and  passes  in  an  arched  line 
outwards  and  downwards  to  reach  the  sixth  rib  a 
little  external  to  the  parasternal  line.  From  this 
point  the  lower  border  passes  backwards  along  a  line 
o 


2IO  Respiratory  System. 

corresponding  to,  but  a  little  lower  than,  that  of  the 
lower  border  of  the  right  lung.  The  lower  borders  of 
both  lungs  are  convex  towards  the  abdomen.  In  forced 
respiration  they  may  vary  in  level  to  the  extent  of 
two  or  even  three  inches,  according  to  the  phase  of 
the  respiratory  cycle.  In  quiet  respiration  the  differ- 
ence between  the  extremes  is  only  about  1  cm. 

2.  LiObeis  of  the  Uiiig^i^. 

It  is  often  important  to  know  the  limits  of  the 
individual  lobes  of  the  lungs.  This  may  be  done  by 
drawing  a  line  from  the  second  dorsal  spine  to  the 
sixth  rib  in  the  mammary  line  ;  this  corresponds  to 
the  upper  border  of  the  lower  lobe.  A  second  line, 
drawn  forwards  on  the  right  side  from  the  centre  of 
this  line  to  meet  the  sternum  at  the  level  of  the  fourth 
costal  cartilage,  will  mark  the  boundary  between  the 
upper  and  middle  lobes. 

Obviously,  therefore,  the  greater  part- of  each  lung, 
as  seen  from  behind,  is  composed  of  the  lower  lobe, 
only  the  apex  belonging  to  the  upper  lobe  ;  whilst  the 
middle  and  upper  lobes  on  the  right  side,  and  the 
upper  lobe  on  the  left,  occupy  most  of  the  area  in 
front.  In  the  axillary  regions^  parts  of  all  the  lobes 
are  accessible. 

The  bifurcation  of  the  trachea  corresponds 
in  front  with  the  lower  part  of  the  manubrium  sterni  ; 
behind  with  the  disc  between  the  fourth  and  fifth 
dorsal  vertebrae. 

The  reflected  pleural  sacs  reach  decidedly 
lower  than  the  inferior  borders  of  the  lungs,  whoselimits 
they  overstep  for  about  two  inches  in  the  mammary, 
nearly  four  inches  in  the  mid-axillary,  and  one  and 
a-half  inches  in  the  scapular  lines.  The  sinus  thus 
formed  lies  on  the  left  side  above  the  resonant  stomach 
cavity,  and  therefore,  should  it  become  distended  with 
fluid,  as  in  cases  of  hydrothorax,  a  dull  area  will  be 
discovered   at  a  part  where  the   healthy   percussion 


Anatomy.  211 

note  is  tympanitic.  The  anterior  i-eflection  of  the 
left  pleura  below  the  fourth  rib  is  considerably  nearer 
the  middle  line  than  the  anterior  border  of  the  left 
lung ; «  hence  in  emphysema,  when  the  lung  presses 
forward  into  this  available  space,  the  area  of  absolute 
cardiac  dulness  is  greatly  encroached  upon. 

With  reference  to  the  correspondence  of  points  in 
front  and  at  the  back,  Quain  gives  the  following- 
relations  as  existing  during  expiration  : — 

"  The  upper  margin  of  the  sternum  is  on  a  level 
with  the  disc  between  the  second  and  third  dorsal 
vertebrae ;  the  junction  of  the  manubrium  and  body- 
is  opposite  the  fifth  dorsal  vertebra;  and  the  xiphi- 
sternal articulation  generally  corresponds  to  the  lower 
part  of  the  ninth  dorsal  vetebra." 

The  scapula  is  a  useful  landmark  posteriorly. 
Its  upper  angle,  when  the  arms  hang  by  the  side,  is 
generally  on  a  level  with  the  disc  between  the  first 
and  second  dorsal  vertebrae,  the  root  of  the  spine  with 
that  between  the  third  and  fourth  dorsal  vertebrae, 
and  its  lower  angle  with  the  body  of  the  eighth  dorsal 
vertebra. 

In  reference  to  the  ribs,  the  upper  angle  of  the 
scapula  just  covers  the  second  rib ;  the  lower  angle 
reaches  as  low  as  the  seventh  interspace  or  eighth  rib. 
The  twelfth  rib  cannot  always  be  felt.  It  is  not 
safe,  therefore,  to  count  the  ribs  from  below  upwards. 
For  convenience  in  description,  the  thoi'ax  is 
mapped  out  into  regions,  as  follows  : — 

icb)  T'liree  central  regions  anteriorly. 

Suprasternal^  from  the  cricoid  to  the  upper 

border  of  the  manubrium. 
Superior   sternal,    from    the    upper   border 
of  the  manubrium   to  the  level  of  the 
third  chondrosternal  articulation. 
Inferior  sternal,  from  third  chondrosternal 
articulation  to  lower  end  of  sternum. 


212  Respiratory  System. 

These  three  regions  are  bounded  laterally  by 
the  lateral  sternal  lines  and  their  upward  con- 
tinuations."^ 

(6)  Five  aiifero-lateral  regions  on  each  side. 

Sujyradavicular  bounded  above  by  an 
oblique  line  from  the  side  of  the  cricoid 
to  the  outer  end  of  the  clavicle,  below 
by  the  clavicle. 

Clavicular,  composed  of  the  area  occupied 
by  the  clavicle. 

Infraclavicular^  bounded  above  by  the 
clavicle,  below  by  a  horizontal  line  at 
the  level  of  the  third  chondrosternal 
articulation. 

Maimiiary,  from  the  lower  edge  of  the 
infraclavicular  area  to  the  level  of  the 
sixth  chondrosternal  junction. 

Inframammary ,  below  that  level. 
These    regions    extend   outwards  to   the   anterior 
axillary  line. 

(c)  Two  lateral  areas  on  either  side. 

.    .,7  [      meeting    each     other 

Axillary  \        .     j_i       i       i       ^    xi 

T  r  -n  {at    the   level    or    the 

imra-axillarii  \        •    ,^      ^^ 

•^  '      sixth  rib. 

{(1)    Four   reg^ioiis   at  the  hack  on   either 
side  of  the  spine. 

Suprasca,pular. 

Scapular,  subdivided  into  supra-  and  infra- 
spin  ous. 

Infrascajndar,  and 

Interscapular. — The  position  of  the  dorsal 
regions  is  sufficiently  defined  by  their 
names. 

*  Sometimes  the  sternal  regions  are  classified  as  "episternal" 
and  "xiphisternal." 


I.VSPECriON. 


213 


SECTION  IT.— INSPECTION. 


Inspection  determines  : — 

(A)  Form  of  chest. 

(«)  Healthy. 

{b)  Symmetrical  chests  with 
features  indicating  pro- 
clivity to  disease. 

{c)  Symmetrical  chests  with 
features  indicating  past 
disease. 

[d)  Symmetrical  chests  with 
features  indicating  pre- 
sent disease. 


ie)  Unilateral  changes. 


(/)  Local  changes. 

(B.)  Movements  o£  chest. 
[a)  Respiratory. 

(1)  Kate. 

(2)  Rhythm. 

(3)  Type. 


I  The  alar  chest. 
i  The  flat  chest. 

[  The  rachitic  chest. 
'  The  pigeon  breast. 
(  Harrison's  sulcus. 

I  The  barrel- shaped  chest. 
I  Bilateral  retraction. 

I  Enlargement. 

(  Diminution. 

/  Bulging. 

1  Retraction. 

\  Funnel-shaped    depres- 

\  sion. 


(4) 


Character    [see 
Chapter  II. ). 


also 


j'  Amount  of  expansion. 
\  Unilateral  fixation. 
I  Local  lagging. 
I  Local     indrawing    and 
(  bulging. 

{b)  Xon-respiratory.      Pulsations  (Chapter  IV.). 

(A)  The  sliape  of  the  tliorax  depends  partly 
on  the  curvature  and  obliquity  of  the  ribs,  partly  on 
the  curves  of  the  spinal  column.  The  curvature  of 
the  sternum  results  from  the  relations  of  these  factors 
in  each  case. 

When  tlie  ribs  are  normally  curved,  the  more 
horizontally  they  lie,  the  more  nearly  does  a  cross 
section  of  the  chest  approach  the  form  of  a  circle, 
the  wider  are  the  intercostal  spaces,  and  the  more 
obtuse  does  the  subcostal  angle  become  ;  whilst  on 
the  contrary,  increasing  obliquity  of  the  ribs  leads  to 


214  Respiratory  System. 

narrowing  of  the  intercostal  splices,  to  increasing  ellip- 
ticity  of  the  cross  section  of  the  chest,  the  major  axis 
lying  transversely  and  the  minor  axis  in  an  antero- 
posterior direction,  and  at  the  same  time  the  subcostal 
angle  becomes  more  acute.  In  a  healthy  male  the  angle 
is  about  70°,  in  the  female  about  75°,  The  variations 
may  amount  to  10°  above  or  below  these  averages. 
When  there  is  lateral  curvature  of  the  spine^the  chest 
is  rendered  asymmetrical  ;  when  the  spine  is  unduly 
concave  forward,  other  changes  are  produced  which 
will  be  dealt  with  subsequently. 

The  ideal  healthy  chest  will  conform  to  the 
following  description  :  It  is  bilaterally  symmetrical, 
its  contours  are  smooth,  it  has  no  deep  hollows,  and 
at  most  shows  only  a  slight  recession  below  the 
clavicles.  In  cross  section  it  is  an  ellipse,  broader 
from  side  to  side  than  from  front  to  back  in  the 
proportion  of  about  7  to  5  ;  and  its  general  shape 
is  ellipsoidal,  with  the  longest  axis  vertical.  In 
children  the  cross  section  is  much  more  nearly 
circular. 

The  sternum,  which  is  convex  from  above  down- 
wards when  viewed  from  the  front,  lies  at  the  bottom 
of  a  shallow  groove  known  as  the  sternal  furrow, 
formed  by  the  pectoral  muscles  of  each  side.  The 
junction  of  the  manubrium  with  the  body  of  the 
sternum  exhibits  a  slight  angular  projection  (angulus 
Ludovici),  sometimes  visible,  almost  always  palpable. 
The  sternal  furrow  ends  below,  at  the  level  of  the 
seventh  costal  cartilage,  in  the  infrasternal  depression 
(or  scrobiculus  cordis).  A  slight  hollow  below  the 
clavicle  marks  the  separation  between  the  divisions 
of  the  pectoralis  major ;  it  should  not  be  deep,  and 
ought  only  to  be  distinct  when  the  muscle  is  made  to 
contract.  A  second  hollow,  which  is  mucb  more 
distinct,  separates  the  pectoralis  from  the  deltoid. 
This  fossa  lies  farther  from  the  middle  line,  and  is 


The  Normal  Chest.  215 

known  as  the  infra-clavicular  (or  Morenheim's)  fossa. 
It  becomes  very  marked  in  many  cases  of  phthisis. 

The  shape  in  the  mammary  regions  depends 
greatly  on  the  degree  of  development  of  tlie  mammary 
gland  and  on  the  amount  of  subcutaneous  fat.  In 
the  adult  male  the  nipple  is  usually  situated  about 
4  in,  from  the  middle  line,  in  the  fourth  intercostal 
space. 

In  actual  practice  it  is  very  rare  to  find  a  chest 
which  is  perfectly  symmetrical.  Generally  the  right 
side  is  rather  more  capacious  than  the  left,  and  the 
spinal  column  almost  always  has  a  slight  degree  of 
lateral  curvature.  In  inspection  of  the  chest  the 
examiner  must  never  be  content  with  viewing  it  from 
one  aspect  only.  He  should  tirst  look  at  it  from  the 
front,  then  from  the  side,  thereafter  from  the  back, 
and  finally  he  should  look  over  the  shoulders  from 
behind  and  above,  so  as  to  see  the  profile  of  a  horizon- 
tal section  of  the  thorax.  The  last  method  is  very 
useful  in  detecting  lack  of  symmetry  or  unequal 
expansion  on  the  two  sides.  The  neck,  especially  as 
regards  the  manner  in  which  it  is  set  on  the  chest, 
and  the  epigastrium  should  be  inspected  at  the  same 
time  as  the  thorax. 

Deviations  from  the  normal  form  may  either  affect 
the  whole  of  the  thorax  or  localised  parts  of  it.  The 
abiioriiial  shapes  of  the  chest  as  a  whole  may 
be  grouped  in  three  classes,  according  as  they  indicate 
merely  a  proclivity  to  lung  disease,  a  history  of 
former  disease,  or  the  existence  of  present  disease. 
The  first  class  contains  the  alar  and  flat  chests  ; 
the  second  the  rickety  chest,  the  pigeon  breast,  and 
the  chest  with  Harrison's  sulcus  ;  the  third  includes 
the  barrel-shaped  chest  and  the  hollow  or  retracted 
chest. 

In  these  groups  the  changes  affect  both  sides  of 
the  thorax,  and  so  the  symmetry  remains  undisturbed. 


2l6 


ReSPIR a  TORY   SVS TEM. 


In  other  instances  the  morbid  conditions  at  work  may 
lead  to  unilateral  changes  in  the  shape  of  the  chest, 
one  side  having  its  volume  either  increased  or  dimi- 
nished, and  being  otherwise  deformed.  Lastly,  the 
chest  may  exhibit  local  deviations  from  the  normal 
form,  due  generally  to  local  disease. 

I.  Syninietrical  chests  with  features 
iudicatiug^      proclivity      to     luiig^      diseases 

("  Phthinoicl '^    Chests) The   two    forms   which 

belong  to  this  class  are  the  alar  and  the  flat  chest. 

I.  The  alar  chest  is  one  where  the  vertebral 
borders  of  the  scapulae  project  unduly,  and  the 
shoulders  droop.     The  cause  of  this  appearance  is  to 

be  found  in  the  obliquity 
of  the  ribs,  which  makes  the 
projection  of  their  curves 
and  angles  in  the  horizontal 
plane  more  sharp,  leads  to 
a  long  and  rather  shallow 
thorax,  and  is  associated  with 
a  long  neck  and  prominent 
throat. 

2.  The  flat  chest  is  due 
to  a  loss  of  the  forward  con- 
vexity of  the  costal  cartilages, 
which  become  more  or  less 
straight.  As  a  result,  the 
sternum  is  less  distant  from 
the  vertebral  column  than  usual.  The  flat  chest  is 
often,  but  not  always,  associated  with  the  alar  form. 

II.  Syiniiietrical  chests  Avith  features 
iudicatiiig  past  diseases  (and  not  seldom  pre- 
disposing to  pulmonary  disease). 

This  group  contains  a  number  of  forms,  but  only  a 
few  need  be  considered  here. 

1.  The  rachitic  chest. — In  rachitis  the  bones 
are  less   rigid  than   usual,   and  so   are  more   readily 


Fig.  64.  —Cross  section  of  rach- 
itic chest.  (Gee.)  The  dotted 
line  represents  the  normal 
outline  for  the  same  age. 


A  BNOR  MA  L    ChES  TS. 


217 


deformed  by  any  applied  force.  From  the  nature  of 
the  disease  the  part  that  yiehls  most  readily  is  where 
the  bone  and  cartilage  meet,  and  therefore,  when  any 
cause  prevents  the  free  access  of  air  to  the  luugs 
during  inspiration,  this  part  bends  inwards  before 
the  pressure  of  the  external  air.  A  vertical  groove 
is  thus  formed  in  this  region,  and  persists  even  after 
the  cause  which  first  led  to  its  production  has  dis- 
appeared. The  section  of  a  rachitic  chest  is  shown 
in  the  accompanying  woodcut,  where  the  depressions 
situated  at  a  little  distance  from  either  side  of  the 
sternum  are  easily  recognised.  AYhen  the  rachitic 
condition  is  severe  the  line  of  least  resistance 
becomes  so  weak  that  no  unusual  obstruction  to 
inspiration  is  necessary  in  order  to  produce  the 
grooves ;  the  slightly  lower  air  pressure  ^\'ithin  the 
thorax,  which  is  necessarily  present  during  in- 
spii'ation,  being  sufficient  to  lead  to  its  formation 
(Fig.  64). 

2.  The  pigeon  breast. — ^Here  in  consequence 
of  some  obstruction  (often  quite  trivial)  to  inspiration 
at  a  time  of  life  when  the 
ribs  are  soft,  they  become 
straightened  in  front  of 
their  angles  ;  where,  owing 
to  their  smaller  degree  of 
curvature,  they  are  most 
readily  deformed  by  ex- 
ternal pressure.  The  re- 
sult is  that  the  sternum 
becomes  unduly  prominent 
and  projects  beyond  the 
plane  of  the  front  of  the 
abdomen,  so  that  there  is 
a  sharp  angle  at  its  lower  end.  At  the  same  time 
the  cross  section  of  the  chest  ceases  to  be  elliptical, 
and  approaches  a  triangular  form,  the   angles  being 


Fig.  65. — Cross  section  of  pigeon 
breast,  {(ite.)  The  dotted  line 
represents  the  normal  outline. 


2i8  Respiratory  System. 

situated  at  the  sternum  in  front,  and  at  the  costal 
angles  behind  (Fig.  65). 

3.  Harrison's  sulcus. — This  is  a  transverse 
constriction  which,  beginning  at  the  level  of  the 
xiphisternum,  passes  outwards  and  slightly  down- 
wards. It  seldom  reaches  as  far  as  the  midaxillary 
line.  This  deformity  is  due  to  the  same  cause  as  the 
last,  but  either  the  obstruction  has  been  slighter,  or 
the  bones  have  been  more  fully  hardened. 

The  depression  is  therefore  limited  to  the  most 
yielding  part  of  the  chest,  and  this  corresponds  to  the 
region  where  the  cavity  is  widest.  Lower  down  than 
the  sulcus,  the  liver  and  other  abdominal  viscera  had 
supported  the  chest  wall  and  so  prevented  it  from 
being  drawn  inwards  ;  whilst  higher  up,  the  greater 
curvature  of  the  ribs  had  enabled  them  to  withstand 
the  external  pressure. 

The  three  deformities  just  described  are  frequently 
found  together  in  one  individual,  and  cases  of  pigeon 
breast  almost  invariably  exhibit  a  well-marked 
Harrison's  sulcus. 

III.  Symmetrical  chests  with  features 
indicating^  present  <lisease. 

1.  In  emphysema  the  increased  volume  of  the 
lungs  demands  increased  space  for  their  accommodation. 
To  provide  this,  the  ribs  are  less  obliquely  set  than 
usual,  whilst  the  spine  becomes  unduly  concave  for- 
wards, and  the  sternum  is  much  more  arched  than 
under  normal  conditions,  whilst  the  angle  of  Louis 
becomes  extremely  prominent. 

Since  this  increase  of  volume  is  accomplished  by 
the  mechanism  which  is  provided  for  the  expansion  of 
the  chest  in  inspiration,  the  latter  can  only  be  effected 
by  movements  of  the  chest  as  a  whole,  and  so  the 
accessory  muscles  of  respiration  have  to  take  the 
place  of  the  intercostals,  thereby  becoming  abnormally 
conspicuous,  whilst  the  diaphragm  has  a  considerable 


Abnormal  Chests.  219 

^cess  of  work  imposed  upon  it.  The  chest  of  eni- 
physenica  is  described  as  "  barrel-sliaped." 

Kypliosis  may  produce  a  form  of  chest  which 
closely  simulates  that  of  emphysema. 

2.  Bilateral  liollowiiig'  is  an  extreme  case  of 
the  flat  chest  already  described  and  is  caused  by  the 
existence  of  phthisis. 

IV.  Unilateral  changes  in  the  shape  of 
the  eiiest  v  hich  aflfect  the  n  hole  of  one  side. 
— These  may  result  either  in  unusual  bulging  or  in 
retraction. 

Unilateral  enlargement  results,  either  from 
the  presence  of  fluid,*  or  gas  in  the  pleura,  or  from 
increase  in  volume  of  one  lung  due  to  a  tumour,  or  to 
compensatory  hypertrophy. 

Diminution  of  volume  results  from  shrinkage 
of  the  lung.  This  may  be  caused  by  phthisis,  or  it 
may  be  the  result  of  adhesions  formed  during  an 
attack  of  pleurisy  with  eff'usion.  Collapse  of  a  lung 
from  obstruction  of  the  bronchi  may  produce  a  similar 
result. 

Before  connecting  these  changes  with  disease  of 
the  lungs  or  pleura,  the  observer  must  ascertain  that 
no  scoliosis  exists  ;  for  the  rotation  of  the  vertebrae 
in  this  condition  leads  to  a  deformity  which,  when 
inspected  only  from  the  front,  it  is  almost  impossible 
to  discriminate  from  those  just  described.!  Ab- 
dominal disease  must  also  be  excluded. 

V.  L-ocal  changes,  affecting  only  part  of  either 
side. 

*  The  presence  of  fluid  does  not  always  cause  enlargement  of 
the  affected  side  of  the  chest,  although  it  often  does  so.  Sometimes 
indeed  that  side  is  smaller.  The  explanation  is  not  ver}-  obvious, 
but  it  most  be  recollected  that  the  fluid  is  primarily  accommodated 
by  displacement  of  the  lung,  and  only  later,  after  the  elasticity 
of  the  lung  has  been  exhausted  will  the  contour  of  the  thorax  be 
altered. 

t  Scoliosis  may,  however,  be  induced  by  the  retraction  of  a  lung 
in  a  young  subject. 


2  20  Respiratory  System. 

1.  Biilg-ing". — In  emphysema  the  apices  may 
produce  an  unusual  fulness  aljove  the  clavicles,  and  in 
pleural  effusion,  especially  when  of  a  purulent  nature, 
the  interspaces  which  lie  in  the  area  of  effusion  often 
bulge  considerably  ;  these  phenomena  may  accompany 
a  general  enlargement,  or  occur  without  it. 

Tumours  of  various  kinds,  and  disease  of  the 
heart  may  be  the  cause  of  localised  bulging. 

2.  Slirinliiiig — In  phthisis  one  or  both  apices 
are  often  contracted  and  thereby  a  hollowing  is 
produced  above  the  clavicles.  A  similar  condition 
occurs  also  in  the  infra-clavicular  regions,  which  may 
exhibit  marked  hollowing.  This  is  particularly 
noticeable  in  Morenheim's  fossa. 

To  detect  either  bulging  or  flattening  (as  well  as 
diminished  expansion)  it  is  important  to  look  tan- 
gentially  along  the  chest  either  from  above  the 
shoulders  or  upwards  from  below.  Both  in  phthisis 
and  other  wasting  diseases  the  interspaces  are  very 
sunken,  and  the  ribs  prominent,  in  consequence  of 
the  malnutrition  of  the  muscles  and  subcutaneous 
tissues. 

Not  infrequently  a  local  shrinking  is  due  to  ad- 
hesions of  the  pleura  resulting  from  a  former  attack 
of  pleurisy. 

3.  A  liiiiiiel-shaped  depression  is  sometimes 
found  in  the  lower  part  of  the  middle  line  of  the 
thorax  on  front.  Sometimes  it  is  congenital,  or  it 
may  be  developed  in  infancy  with  or  without  any 
obstruction  to  respiration  being  present.  It  extends 
in  some  cases  as  high  as  to  the  third  rib.  A  similar 
depression — though  seldom  of  such  magnitude — is 
found  as  a  trade  deformity  in  shoemakers. 

(B)  Movements  of  the  tliorax. 

The  movements  of  the  chest  during  respiration 
also  demand  attention,  and  the  rate  of  movement,  its 
rhythm,  its  type,  and  its  amount  must  be  noted. 


ATOVEMENTS    OF    ClIEST.  22  1 

The  rato  for  an  adult  in  liealtli  is  about  eighteen 
or  twenty  resj^irations  per  minute,  but  there  is  a  wide 
margin  on  either  side  of  these  figures.  Increased 
rapidity  may  result  from  exertion,  nervous  excite- 
ment, fever,  defective  aeration  of  the  blood,  whether 
this  be  due  primarily  to  cardiac,  pulmonary,  bronchial, 
and  laryngeal  causes,  or  to  some  alteration  in  the 
oxygen-carrying  power  of  the  blood.  It  may  also 
arise  from  the  association  of  pain  with  all  attempts  at 
respiration,  as  in  pleurisy  and  peritonitis,  when  the 
breathincj  becomes  shallow,  and  must  therefore  be 
more  frequent  to  make  up  for  the  slighter  expansion. 

The  ratio  between  respiration  and  the 
pulse  is  important.  In  health  it  is  about  1  to 
4  ;  in  pneuuionia  respiration  may  occur  almost  as 
frequently  as  the  pulse ;  in  certain  cases  of  narcotic 
poisoning  the  ratio  may  become  1  to  6  or  7. 

2.  The  rliythni  varies  very  considerably  even  in 
health,  and  if  the  act  be  performed  consciously  it 
may  become  very  irregular.  Hence  it  is  important 
to  study  it  when  the  patient  is  off  his  guard,  as  only 
then  can  accurate  observations  be  made.  Either 
inspiration  or  expiration  may  be  unduly  prolonged ; 
the  former  being  commonly  associated  with  laryngeal 
or  tracheal,  the  latter  with  bronchial  and  pulmonary 
diseases.  A  peculiar  type,  where  successive  respira- 
tions gradually  get  deeper  and  deeper  till  a  maximum 
is  attained,  and  then  fall  off  again  until  a  pause  of 
complete  apnoea  occurs,  to  be  followed  by  another 
wave  of  gradually  deepening  and  then  diminishing 
respirations,  is  known  as  Cheyne-Stolses  breath- 
ing". The  pause  may  last  for  fully  half  a  minute, 
though  it  is  often  shorter,  and  the  whole  cycle  is 
usually  completed  in  less  than  two  minutes.  It  is 
very  conspicuous  w^hen  the  patient  who  exhibits  it  is 
asleep,  or  is  unconscious ;  but  is  apt  to  be  overlooked 
if   the    patient  is  awake,   and  particularly   if    he    is 


222  Respiratory  System. 

talking.  Apart  from  completely  typical  Cheyne- 
Stokes  respiration,  various  modifications,  more  or  less 
nearly  approaching  it,  occur. 

There  is  another  form  of  respiration  which  is 
often  mistaken  for  Cheyne-Stokes  breathing,  but 
which  is  really  diflerent.  In  this  form,  instead  of  a 
gradual  increase  in  the  depth  of  respiration  from  the 
apnoeic  pause  to  the  middle  of  the  cycle,  the  deep 
breathing  begins  suddenly,  and  gradually  diminishes, 
until  the  apncEic  pause  is  reached,  thereafter  to  re- 
commence once  more  with  full  vigour. 

3.  Type. — Breathing  may  be  more  evidently  per- 
formed by  the  upper  part  of  the  thorax ;  this  is 
known  as  the  thoracic  type  of  respiration.  It 
is  found  to  a  certain  degree  in  women,  but  in  its  full 
development  is  associated  either  with  paralysis  of  the 
diaphragm,  or  else  as  a  result  of  its  fixation  from  in- 
flammatory causes  or  increased  abdominal  pressure. 

In  men  and  young  children,  the  diapliragin 
and  abdominal  muscles  play  the  most  important 
part  in  respiration;  and  in  cases  where  the  intercostal 
muscles  are  paralysed,  or  where  some  inflammatory  and 
painful  conditions,  such  as  pleurisy,  or  pleurodynia, 
exist  in  the  thorax,  the  breathing  may  be  wholly 
abdominal  in  type. 

In  health  the  male  type  of  respiration  may  be 
described  as  al>domino-thoracic,  the  female  as 
tUoracico-abdominal,  or  almost  purely  thoracic. 

The  presence  of  pain  or  dyspnoea  should 
should  always  be  inquired  for,  and  its  exact  nature 
noted.     \See  Chap.  II.] 

4.  Kegarding  "  movement "  during  respiration, 
the  points  to  be  noted  are  its  amount,  whether  it  is 
expansive  in  character,  and  whether  it  is  similar  on 
the  two  sides  and  over  corresponding  areas. 

Amount  of  movement  and  expansion  are  by  no 
means   interchangeable    terms;    in    emphysema   the 


Palpation.  223 

chest  may  move  considerably,  but  there  is  little  ex- 
pansion. 

In  comparing  the  two  sides  it  will  often  be  found 
that  deficient  or  absent  movement  betokens  pleurisy 
with  effusion,  or  non-expansion  of  the  lung  from  con- 
solidation or  rigidity  of  its  structure, 

Local  tlelicieiicy  in  expansion  is  frequently 
a  very  important  indication  of  phthisis,  or  it  may  be 
due  to  lobar  pneumonia,  the  former  especially  at  the 
apices,  the  latter  at  the  apex  or  base  according  to  the 
situation  of  the  disease. 

Sometimes  one  part  of  the  chest  wall  lags  behind 
the  rest  during  inspiration  Any  such  lagging  is  im- 
portant as  suggestive  of  disease.  The  existence  of 
any  indrawing-  of  the  chest  wall  or  of  the  inter- 
spaces during  inspiration,  or  of  any  bulging^  during 
expiration,  must  be  noted.  Both  may  occur  physio- 
logically, in  which  case  the  conditions  are  present 
over  the  whole  chest,  and  are  not  very  conspicuous, 
or  they  may  result  from  pathological  conditions,  when 
they  sometimes  affect  the  whole  thorax,  at  other 
times  one  side,  and  yet  at  others  only  appear  locally. 
Examples  of  inspiratory  indrawing  are  found  in  ob- 
struction of  the  larynx  (general),  or  in  blocking  of 
some  of  the  smaller  bronchi  (local).  One  of  the  best 
instances  of  localised  expiratory  bulging  is  seen  at 
the  apices  of  the  lungs  in  advanced  emphysema. 


SECTION  III.— PALPATION. 

Palpation  determines : — 

A.  Form  of   chest   [confirms  or   modifies   th.e   results   of 

inspection,  q.v.^ 

B.  Movements  of  chest. 

a,  Respiratory  \yide  also  inspection], 
J,  Pulsations  [Chap.  IV.]. 


2  24  Respiratory  System. 

/  Palpable  pleuritic  friction. 

C.  Vibrations  P^lP''^^^^  ^■^^^'-       ,. 

I  ( increased. 

\  Vocal  fremitus      I  diminished. 
(  absent. 

D.  Tenderness, 

E.  Fluctuation. 

F.  Resistance  of  chest  wall  to  compression. 

Inspection  of  the  thorax  should  go  hand  in  hand 
with  palpation  and  mensuration.  In  this  way  the 
observations  made  by  the  eye  are  confirmed  and 
extended,  in  some  respects  greater  accuracy  is 
attained,  and  various  facts  which  the  eye  cannot 
discover  are  elicited. 

Palpation  takes  note  firstly  of  the  form  and  move- 
ments of  the  thorax ;  secondly,  of  vibrations  or 
tremors  wliich  are  communicated  to  the  hand  ;  and 
thirdly,  of  the  behaviour  under  pressure  of  any  pain 
of  which  the  patient  complains.  Under  the  first  head 
inspection  is  supplemented ;  under  the  second  one 
learns  something  of  the  accompaniments — e.g.  friction, 
or  rhonchi — which  interrupt  the  smoothness  of  the 
respiratory  movement,  and  also  of  vocal  fremitus, 
which  serves  to  indicate  the  condition  of  the  con- 
ducting media.  The  third  enables  one  to  detect  the 
cause  of  many  thoracic  pains. 

Before  making  a  systematic  examination,  it  is 
well  to  lay  the  hand  on  any  part  of  the  chest  which 
presents  an  obvious  swelling,  or  where  the  patient 
complains  of  pain.  In  doing  so  the  observer  should 
remember  to  look  at  the  jDatient's  face  rather  than  at 
the  part  under  examination,  as  he  thus  most  quickly 
learns  whether  he  is  causing  any  avoidable  suffering. 
Pain  may  be  due  to  inflammatory  conditions  in  the 
chest  wall,  to  intercostal  neuralgia,  where,  as  a  rule, 
specially  painful  spots  can  be  discovered  corresponding 
to  the  points  where  the  branches  of  the  affected  nerves 
emerge    through    the    fascia ;   to   intercostal  myalgia. 


Palpation. 


2-^5 


where  the  pain  is  aggravated  by  pincliing  the  afTected 
muscle,  or  to  pleurisy.  In  the  case  of  the  latter, 
pressure  may  considerably  increase  the  pain  by  bring- 
ing the  opposed  surfaces  of  the  inflamed  pleura  more 
firmly  into  contact.  At  the  same  time  the  nature  of 
any  swelling  should  be  investigated.  The  hand  will 
also  supplement  the  information  derived  from  inspec- 
tion with  regard  to  prominence  of  the  intercostal 
spaces,  and  may  occasionally  detect  fluctuation  in 
them  when  there  is  pleuritic  effusion.  Fluctuation 
also  occurs,  and  is  much  more  distinct  when  an  ab- 
scess has  formed  in  the  chest  wall.  Such  an  abscess 
may  be  due  to  disease  of  the  bones  or  soft  parts 
forming  the  parietes  of  the  thorax,  or  to  pus  which 
has  broken  through  from  the  pleural  cavity  {empyema 
necessitatis).  In  the  latter  case  the  pus  may  often 
be  driven  back  by  gentle  pressure,  to  reappear  when 
the  patient  coughs. 

When  these  preliminary  observations  have  been 
completed,  the  observer  should  direct  his  attention  to 
the  form  of  the  thorax.  Here  the  hand  is  best 
aided  by  mechanical  appliances,  such  as  the  cyrto- 
meter  and  by  simple  measurements.  Tracings  and 
measurements  should  be  taken  at  the  periods  of  full 
expiration  and  inspiration.  In  a  well-formed  adult 
male  the  girth  of  the  chest  at  the  level  of  the  nipples 
should  be  34  inches  at  the  end  of  expiration,  and 
should  measure  at  least  two  inches  more  when  a 
deep  inspiration  has  been  taken.  Height,  age,  and 
build  of  course  greatly  modify  these  measurements, 
and  insurance  returns  indicate  that  different  races 
vary  very  considerably  in  chest  girth.  It  is  generally 
far  more  important  to  ascertain  the  increase  of  girth 
between  inspiration  and  expiration,  both  full  and 
ordinary,  than  to  determine  the  exact  circumference 
of  the  chest  at  either  phase. 

If  the  shape  of  a  cross  section  of  the  chest  is 
p 


2  26  Respiratory  System. 

re(]^uired,  a  tolerably  efficient  cyrtometer  can  be 
improvised  by  connecting  two  pieces  of  flattened 
composition  gas-pi])e,  each  about  two  feet  long,  by  a 
hinge  of  elastic  tube.  The  hinge  should  be  placed 
over  the  spine,  and  the  metal  pipe  moulded  to  the 
surface  of  the  chest.  It  can  then  be  opened  at  the 
hinge  and  closed  again  over  a  piece  of  paper,  to 
which  the  outline  should  be  transferred  if  a  per- 
manent record  is  desiied.*  There  is  no  difficulty  in 
applying  the  same  simple  instrument,  so  as  to  obtain 
the  outline  of  the  chest  in  other  planes  than  the  hori- 
zontal. Thus  by  placing  the  hinge  above  the  shoulder 
the  two  pieces  of  pipe  may  be  carried  down  the 
parasternal  line  in  front  and  in  a  corresponding  line 
behind,  whilst,  by  sharply  bending  their  lower  ends 
outwards^  they  may  be  made  to  cross  each  other  in 
the  axillary  line  and  the  point  of  intersection  marked. 
The  instrument  is  then  opened  at  the  hinge  and  re- 
adjusted over  the  paper  so  as  to  yield  the  desired 
tracing. 

The  nature  of  the  respiratory  moveiueiits 
must  next  be  studied.  It  is  important  to  make 
certain  that  the  two  sides  of  the  chest  move  to 
approximately  the  same  extent.  This  is  done  by 
fixing  the  finger-tips  of  either  hand  at  the  patient's 
sides,  and  making  the  radial  borders  of  the  thumbs 
meet  in  the  middle  line  in  front  of  the  chest.  The 
hands  being  kept  rigid,  the  patient  is  directed  to  take 
a  full  inspiration,  when  the  distance  of  departure  of 
the  thumbs  from  the  middle  line  indicates  the  extent 
of  expansion  of  either  half  of  the  chest. 

Sometimes  one-half  of  the  thorax  lags  behind  the 
other ;  this  is  readily  detected  by  the  hands  no  longer 
moving  synchronously, 

*  Various  more  elaborate  instruments  have  been  devised,  but, 
though  ingenious,  they  are  cumbrous,  and  consequent!}'  not  of 
great  clinical  use.  The  best  of  them  is  Dr.  Graham  Brown's 
l)erigraph. 


Palpation.  227 

Tlie  movements  at  the  apices  may  be  similarly 
observed.  In  this  case  the  physician  stands  behind 
the  patient,  and  fixing  his  thumbs  on  the  vertebrae, 
lets  his  fingers  lie  over  the  right  and  left  lung  apices 
reaching  towards  the  clavicles  whilst  the  patient 
breathes  deeply.  Thereafter  one  hand  should  be 
placed  on  front  of  the  chest,  and  the  other  on 
the  epigastrium.  In  health,  as  the  chest  expands, 
the  epigastrium  is  also  raised  to  a  greater  or  less 
degree.  If  the  epigastrium  fall  in  with  each  expan- 
sion of  the  chest,  there  is  reason  to  suspect  paralysis 
or  llaccidity  of  the  diaphragm.  Fixation  of  the 
diaphragm  with  immobility  of  the  epigastrium  during 
respiration  is  generally  due  to  abdominal  disease 
{see  p.  52.) 

Vibrations  may  be  detected  by  palpation.  For 
this  purpose  the  palm  of  the  hand  should  be  applied 
iiat  on  the  chest,  and  since  the  sensitiveness  of  the 
two  hands  is  often  unequal,  the  same  one  should  be 
employed  on  both  sides.  In  addition  to  the  'S'ibra- 
tions  already  referred  to  in  the  chapter  on  the  heart, 
fremitus  .may  be  due  to  pleural  frjctioii,  to  catarrhal 
changes  in  the  mucosa  of  the  bronchi  leading  to  local 
constrictions,  or  to  fluid  in  the  bronchi  or  in  pul- 
monary cavities.  After  the  presence  or  absence  of 
these  forms  of  fremitus  has  been  determined,  the 
observer  should  study  the  vocal  fremitus,  or 
vibrations  which  the  voice  communicates  to  the  chest 
wall.  These  are  conducted  from  the  larynx  by  the 
trachea  and  bronchi  to  the  smaller  tubes  within 
the  lungs,  and  thence  through  the  lung  tissue  to  the 
surface.  Anything  which  afl^ects  the  conducting 
power  of  the  air-passages,  or  lung  tissue,  or  the 
interposition  of  additional  materials  through  which 
the  vibration  must  pass  to  reach  the  palpating  hand, 
will  obviously  affect  the  intensity  of  the  fremitus. 
To  test  the    vocal    fremitus^  the  patient  is   told    to 


2  28  Respiratory  System. 

repeat  "one,  one,  one,"  or  "  ninety-nine,"  in  a  clear 
voice.  The  hand  placed  on  the  thorax  detects  distinct 
vibration  whilst  this  is  done,  and  it  must  be  deter- 
mined whether  the  vibrations  in  corresponding  areas 
on  the  two  sides  of  the  chest  are  approximately  equal 
in  intensity — not,  however,  forgetting  that  where  the 
heart  encroaches  on  the  left  lung  the  fremitus  is 
necessarily  much  diminished — and  also  whether  they 
correspond  to  what  former  experience  has  led  the 
observer  to  recognise  as  normal  for  the  region  under 
examination,  for  a  similar  chest  and  like  pitch  and 
loudness  of  voice.  Vocal  fremitus  is  increased 
when  the  voice  is  of  a  deep  pitch,  when  the  chest  wall 
is  rigid  and  often  when  it  is  thin,  as  also  when  the 
lung  is  consolidated,  or  contains  a  cavity  near  its 
surface.  Since  the  right  bronchus  is  wider  and 
shorter  than  the  left,  whilst  the  septum  separating 
the  two  bronchi  occupies  a  position  to  the  left  of 
the  centre  of  the  trachea,  the  laryngeal  sounds  pass 
more  freely  along  the  right  than  they  do  along  the 
left  bronchus,  and  therefore  the  vocal  fremitus  is 
normally  somewhat  greater  over  the  right  lung  than 
over  the  left. 

Vocal  fremitus  is  diminished  when  the 
pitch  of  the  voice  is  high,  when  the  chest  wall  is 
thick,  and  especially  when  there  is  much  thickening 
of  the  pleura.  It  is  greatly  diminished,  or  totally 
absent,  when  the  lung  is  separated  from  the  chest 
wall  by  pleuritic  effusion.  The  cause  in  this  case  is 
not  that  fluid  is  a  bad  conductor  of  sound  or  of  vibra- 
tion— the  reverse  is  the  case — but  because  the  relaxed 
lung  itself  fails  to  convey  the  vocal  fremitus,  and  so 
the  vibrations  never  reach  the  fluid.  In  young 
persons  and  in  female  subjects  the  vocal  resonance 
is  different  both  in  character  and  intensity  from  that 
which  occurs  in  male  adults.  The  differences  are  due 
to  the  different  conformation  and  degree  of  rigidity  of 


Percussion.  229 

the  thorax,  and  to  the  distinctiv'e  pitcli  and  quality  of 
the  voice  in  each  instance.  The  resistance  of  the 
chest  to  compression  is  best  estimated  by  placing  the 
hand  over  the  sternum  whilst  the  patient  is  lying 
down,  and  attempting  to  i)ress  it  backwards  towards 
the  vertebral  column.  The  rigidity  naturally  in- 
creases with  advancing  age,  but  observations  also 
indicate  that  in  certain  diseases  {e.g.  in  phthisis  and 
in  emphysema)  the  rigidity  often  becomes  greater 
than  usual.  Where  this  is  so  the  prognosis  is 
rendered  less  favourable,  as  free  expansion  of  the 
lunof  is  hindered. 

SECTION  IV.— PERCUSSION. 

Percussion  determines : — 

A.  The  boundaries  of  the  lungs  [topographical  percussion]. 

B.  The  resonance  of  the  lungs. 

(«)  Normal  variations  in  different  parts. 
[b]  Abnormal  alterations. 

!  Increase  [hyper-resonance]. 
Bimimition,  in  varying  degrees  from 
slight     impairment     to    absolute 
dulness. 

( liigh-pitched. 
2.  Qualitative  : — Tympanitic      |  medium-pitched. 

( low-pitched. 
Skodaic. 
Boxy. 

Cracked- Pot. 

Bell  sound  (coin  percussion.) 
Amphoric. 

But  little  need  be  added  here  to  what  has  been 
already  stated  in  a  previous  chapter  regarding  the 
theory  of  percussion.  It  must  be  recollected  that  it 
is  a  most  difficult  task  to  give  even  a  partial  explana- 
tion of  the  phenomena  observed  from  the  standpoint 
of  physics,  and  in  practice  it  is  rarely  necessary  to 
appeal   to   theory,   as  a  long  experience  has  enabled 


230  Respiratory  System, 

physicians  to  attacli  certain   meanings,   more  or  less 
empirically,  to  v^arious  })ercussion  phenomena. 

It  may,  however,  help  the  student  to  appreciate 
the  various  sounds  when  he  hears  tliem,  if  a  few  of 
the  main  factors  in  their  causation  are  recapitulated. 

Firstly,  we  have  to  consider  the  materials  whicli 
produce  the  sound.  .  These  are  the  pleximeter,  the 
chest  wall  beneath  it,  and  the  subjacent  viscus  so  far 
as  it  comes  within  the  range  of  action  of  the  percus- 
sion stroke.  The  pleximeter  sound,  by  the  choice  of 
a  suitable  material,  may  either  be  rendered  insignifi- 
cant, or,  in  consequence  of  its  special  qualities, 
immaterial  in  its  effect  on  the  resonance.  The 
chest  wall  yields  a  sound  varying  with  the  part 
struck,  and  depending  for  its  quality  on  whether 
sternum,  clavicles,  ribs,  or  soft  parts,  underlie  the 
pleximeter.  The  sound  due  to  the  wall  is,  however, 
quite  subordinate  to  that  of  the  organ  lying  beneath 
when  the  latter  contains  air,  and  when  the  percussion 
stroke  is  firm  enough. 

The  character  of  the  sound  produced 
varies  quantitatively  and  qualitatively,  the  quanti- 
tative variations  depending  on  the  force  of  the  blow 
delivered,  and  on  the  capacity  of  the  part  struck  to 
resound  to  the  blow. 

The  Quality  of  the  sound  depends  on  the 
particular  vibrations  which  are  elicited,  and  on  the 
selective  reinforcement  of  some  of  them  by  the 
resonance  of  the  origans  involved. 

When  the  air  in  a  cavity  of  sufficient  size  and 
appropriate  shape  is  set  into  vibrations  whicli  are  not 
modified  by  excessive  tension  of  the  containing  walls  of 
the  space,  the  sound  heard  has  a  tympanitic  character, 
but  when  the  cavity  is  subdivided  into  a  number  of 
small  loculi  by  numerous  septa,  more  or  less  tense, 
a  characteristic  resonance,  no  longer  tympanitic,  is 
produced.       Such    conditions  prevail  in  the    healthy 


Percussion.  231 

lung,  and  the  observer  must  learn  by  assiduous  prac- 
tice to  recognise  its  distinctive  quality.  In  general 
terms,  this  pulmonary  resonance  may  be  said  to  be 
low  in  pitch  and  clear  in  character. 

In  percussion  over  the  lung  we  endeavour  to  as- 
certain three  sets  of  facts ;  firstly,  the  position  of  the 
apices  and  lower  borders  of  the  lungs,  and  also  of  that 
portion  of  the  anterior  border  of  the  left  lung,  which 
lies  over  the  heart  ;  secondly,  the  state  of  the  lungs 
in  regard  to  the  quantity  of  air  contained  in  their 
various  parts,  and  the  tension  of  their  elastic  frame- 
work ;  and,  thirdly,  whether  they  are  unusually 
remote  from  the  surface  of  the  chest,  the  separation 
being  due  to  thickened  parietes,  or  fluid  or  gas  in  the 
pleural  cavity. 

The  apices  and  borders. 

Owing  to  the  slope  of  the  surface  of  the  neck, 
resonance  can  usually  be  observed  in  health  for  one 
and  a  half  to  two  inches  above  the  level  of  the 
clavicle.  The  apices  are  either  equally  high  above 
the  clavicles,  or  the  right  may  reach  a  shade  higher 
than  the  left,  if  the  right  is  a  little  lower  than  the 
left,  or  the  left  decidedly  lower  than  the  right,  there 
is  a  probability  of  past  or  present  disease  in  the  lung 
whose  apex  fails  to  attain  the  normal  limits.  Should 
both  apices  be  very  low  in  level,  there  may  be  disease 
of  both  lungs.  When  the  examination  is  made  the 
patient  must  look  straight  before  him,  not  turning 
the  head  to  the  side  away  from  the  examiner,  as  this 
alters  the  tension  of  the  muscles  over  the  lung.  The 
percussion  stroke  should  be  moderately  strong,  and 
care  should  be  taken  that  it  is  delivered  quite  per- 
pendicularly to  the  surface. 

The  lowor  toorder  of  the  rig^ht  lung:  lies  over 
the  liver,  and  is  thin,  therefore  its  exact  situation  is 
best  made  out  by  light  percussion.  Posteriorly,  how- 
ever, the  muffling  due  to  the  thick  muscles  and  fat  of 


232  Respiratory  System. 

tlie  back  makes  it  necessaiy  to  percuss  more  firmly. 
When  the  i)atient  is  obese,  very  heavy  percussion 
with  several  lingers  may  be  necessary  in  order  to 
penetrate  the  parietes,  and  bring  the  lung  tissue 
within  the  sphere  of  influence  of  the  blow.  In  quiet 
respiration  the  lower  border  is  found  to  lie  in  the 
mammary  line  at  the  sixth  rib,  in  the  midaxillary  line 
at  the  eighth  rib,  in  the  scapular  line  at  the  tenth 
rib,  and  nearer  the  vertebral  column,  as  low  as  the 
tenth  space. 

On  the  left  side  the  lower  border  overlaps  the 
stomach,  and  so  the  transition  is  not  from  lung 
resonance  to  dulness,  but  to  tympanitic  stomach 
resonance.  Posteriorly,  however,  the  splenic  dulness 
and  the  dulness  of  the  various  solid  structures  which 
lie  below  the  lung  near  the  spine  are  interposed, 
so  that  the  conditions  resemble  those  found  on  the 
right. 

The  position  of  the  lower  border  corresponds 
pretty  closely  with  that  on  the  right  side  ;  it  may, 
however,  be  found  a  trifle  farther  down.  In  old 
people  the  lower  borders  of  both  lungs  extend  beyond 
these  limits,  in  children  they  do  not  reach  them  by 
about  a  rib's  distance  lower  and  higher  respectively. 

The  anterior  border  of  the  left  lung: 
emerges  from  behind  the  sternum  at  the  level  of  the 
fourth  costal  cartilage,  and  forms  the  upper  and  left 
limits  of  the  area  of  superficial  cardiac  dulness. 

The  limits  described  are  exceeded  in  very  deep 
inspiration,  and  in  diseases  such  as  emphysema,  where 
the  volume  of  the  air- containing  lung  is  increased. 
In  pneumothorax  the  lower  border  of  resonance  is 
often  considerably  below  the  limits  assigned,  and  the 
character  of  the  sound  is  different  (p.  237). 

The  limits  are  not  attained  when  the  lungs  are 
shrunken  or  consolidated,  when  increased  abdominal 
pressure    interferes    with    the    normal    level    of    the 


PERCCrSS/OA^. 


233 


diapliragiu,  or  when  there  is  effusion  in  the  cavity 
of  tlie  pleura.  Tn  this  case,  should  the  etfusion  he 
left-sided,  instead  of  passing  in  the  anterior  axillary 
line  from  lung  resonance  to  tympanitic  stomach 
resonance,  a  hand  of  dulness   will  be   found  between 


Fig.  66. — Ti-aube's  space  in  pleuritic  eflfusion. 
a,  portion  rendeied  dull ;  b,  portion  remaining  resonant. 

the  two  resonant  areas ;  and  since  the  lower  limit  of 
the  pleural  sac  reaches  nearly  four  inches  *  lower  at 
this  point  than  the  inferior  border  of  the  lung, 
the  dulness  will  pass  downwards  to  a  lower  level 
than  the  normal  lung  resonance  does,  and  Traube's 
area  (p.  63)  will  be  encroached  npon  (Fig.  66).     In 

*  In  the  cadaveric  condition  Luschka  cnves  it  as  10  cm. 


234  Respiratory  System. 

consolidation  of  the  lung,  on  the  contrary,  this  area 
will  not  be  diminished. 

Having  outlined  the  lungs,  the  character  of  the 
percussion  sound  over  their  various  parts  must  be 
studied.  Beginning  in  front,  the  examiner  should 
tap  lightly  on  the  most  prominent  point  of  each  cla- 
vicle— being  careful  to  ascertain  that  the  points  ex- 
amined correspond  exactly  with  each  other — and  should 
observe  the  quality  of  the  sound,  and  particularly 
determine  whether  under  like  conditions  of  percus- 
sion the  effects  on  either  side  are  identical.  There- 
after the  other  corresponding  areas  on  either  side 
should  be  carefully  compared,  many  points  being 
systematically  percussed  in  each  area.  The  presence 
of  the  heart  will  obviously  interfere,  in  certain  parts 
of  the  left  side,  with  the  development  of  a  sound  re- 
sembling that  on  the  corresponding  point  on  the  right. 

When  the  front  has  been  fully  examined,  the 
observer  should  percuss  in  both  axillary  and  infra- 
axillary  regions — the  patient  meanwhile  holding  his 
hands  joined  above  his  head;  lastly,  the  various  areas 
posteriorly  should  be  worked  out  ;  the  patient,  if  able 
to  sit  up,  being  instructed  to  fold  his  arms  and  bend 
slightly  forwards. 

It  is  most  essential  at  all  parts  of  this  exami- 
nation that  the  patient's  attitude  be  a  comfortable 
one,  so  as  to  avoid  any  unilateral  strain  on  his 
muscles,  and  that  his  arms  and  shoulders  should  be 
placed  symmetrically.  The  head  must  not  be  inclined 
to  either  side. 

If  any  of  the  regions  are  unusually  hollowed  so 
that  the  finger  cannot  be  readily  adapted  to  them, 
a  small  cork  will  be  found  to  make  a  good  pillar 
plexinieter  (p.  116). 

Should  the  patient's  chest  be  unsymmetrical  {e,.g. 
from  spinal  curvature),  the  observer  must  not  expect 
equal  resonance  on  the  two  sides. 


Per  c  u SSI  on.  235 

III  ;t  healthy  individual  the  resonance  in  the 
various  regions  will  exhibit  the  following  character- 
istics : — 

Apices. — Clear,  not  very  intense  as  the  vibrating 
mass  is  small,  and  tending  to  have  a  slight  tympanitic 
quality  added  as  the  trachea  is  approached. 

Clavicular    reg^ioiis Sternal    end.        Clear, 

moderately  intense,  with  tympanitic  element  due  to 
trachea.  Centre.  Clear,  more  intense  than  in  supra- 
clavicular or  outer  clavicular  regions.  Devoid  of 
tympanicity.      Outer  end,  as  centre,  but  less  intense. 

Infra-clavicular  rcg:ion§. — Clear  and  intense. 
Slightly  tympanitic  near  sternum. 

Mainniary  regions. — Here  there  is  naturally 
a  difference  between  the  two  sides ;  on  the  right,  the 
lung  is  encroached  on  in  the  lower  part  of  this 
area  by  the  liver ;  on  the  left,  the  heart  occupies 
a  good  deal  of  the  space,  and  the  stomach  note  is 
elicited  through  the  thin  lung  at  the  lower  part.  In 
general,  however,  the  pulmonary  resonance  is  clear 
and  fairly  intense,  except  where  the  neighbouring 
organs  come  within  the  range  of  vibration.  The 
chest  wall  here  is  thicker  from  the  presence  both 
of  the  pectoral  muscles  and  the  mammary  gland,  and 
the  sounds  elicited  are  consequently  more  muffled. 

In  the  infra-ananiniary  regions  the  sounds 
are  greatly  influenced  by  the  neighbourhood  of  the 
liver,  the  colon,  and  the  stomach.  The  lung-sound, 
however,  is  clear,  though  not  intense,  the  thin  layer  of 
lung  becoming  rapidly  emptier  of  resonance  as  its 
lower  border  is  approached. 

In  the  axillary  regions  the  sound  is  intense 
and  clear,  diminishing  however  in  intensity  at  the 
lower  part  of  each  lateral  area. 

Posteriorly,  the  great  masses  of  muscle  which 
clothe  the  back  muffle  the  resonance  and  make  it 
feebler  ;  and   therefore   tinner  percussion,  often  with 


236 


ReSPIR a  tor  V   Si  '5  TE M. 


several  fingers,  is  requiied.  The  scapular  region  is 
most  muffled,  tlie  infra-scapular  least  so.  The  inter- 
scapular and  supra-scapular  regions  are  intermediate 
in  quality. 

In  disease,  the  resonance  may  be  affected  (1)  quan- 
titatively and  (2)  qualitatively. 

Resonance  is  increased  in  emphysema 
(slightly),  but   at  the  same  time   the  pitch  is  raised 


Fig.  67.— Pleurisy,  with  effusion, 
seeu  from  beliiucl.     (Case].) 


Fig.  68.- Pleurisy,  with 
effusion,  seen  from  the 
side.     (Case  2.) 


by  the  greater  tension  of  the  chest  wall,  and  this 
in  some  cases  not  only  prevents  the  increased  re- 
sonance from  being  observed,  but  almost  suggests 
dulness. 

When  the  lung  tissue  is  relaxed,  but  still  contains 
air,  the  effect  of  the  septa  which  subdivide  the  air 
columns  is  for  the  most  part  abolished,  and  the  sound 
becomes  distinctly  tympanitic.  At  the  same  time, 
the  resonance  is  increased  in  intensity.  This  is  some- 
times called Skoclaic  resonance,  and  occurs  above 


Percussion. 


237 


the  level  of  a  pleural  ettusion,  or  in  the  upper  [)ortion 
of  a  lung  whose  lower  lobe  is  affected  hy  pneumonic 
consolidation.  When  air  has  found  its  way  into 
the  pleural  cavity,  the  sound  is  as  a  rule  intensely 
tympanitic,  unless  the  air  be  under  considerable  pres- 
sure. A  characteristic  form  of  high-pitched  tym- 
panitic resonance  may  be  heard,  in  pneumothorax,  by 
percussion  over  the  front  of  the  chest  with  a  couple  of 
coins ;  one  being  used  as  a 
plessor  and  the  other  as  a 
plexiraeter,  whilst  the  ob- 
server listens  at  the  back  of 
the  patient.  Jn  very  marked 
cases  the  sound  is  soft  and 
musical,  and  has  been  com- 
pared to  the  chiming  of  a 
distant  church  bell ;  in  cases 
that  are  less  pronounced  it 
approximates  rather  to  the 
stroke  of  a  hammer  on  an 
anvil  when  heard  a  long 
way  off. 

Cavities  in  the  lung,  or 
the  presence  of  large  or  me- 
dium bronchi  within  range 
of  the  percussion  stroke,  like- 
wise cause  the  sound  to  become  tympanitic.  A 
tympanitic  sound,  which  may  closely  resemble  that 
caused  by  the  presence  of  a  vomica,  is  heard  when 
the  portion  of  lung  which  lies  between  the  trachea  or 
primary  bronchi  and  the  surface  becomes  consoli- 
dated. This  sound  is  sometimes  called  "  Williams's 
tracheal  resonance,"  and  is  most  frequently  discovered 
in  the  first  or  second  intercostal  spaces  near  the 
sternum.  It  is  by  no  means  an  uncommon 
phenomenon. 

Resonance  is  cliniinislied  in  cases  where  the 


Fig  69. — Pleurisy,  with  effusion, 
seen  from  the  front.     (Case  1.) 


238  Respiratory  System. 

pleura  is  thickened,  or  where  there  is  consolidation 
of  the  lung,  either  of  a  whole  lobe,  as  occu?\s  in  pneu- 
monia, or  of  small  patches,  as  in  early  phthisis.  In 
the  latter  instance  a  particular  strength  of  percussion 
stroke  will  in  each  case  be  found  to  develop  the 
dulness  to  the  best  advantage,  according  to  the  size 
of  the  solid  patch  and  its  distance  from  the  surface. 
When  fluid  is  present,  as  in  hydrothorax  or  pleurisy 
with  effusion,  the  dulness  is  absolute,  and  an  unusual 
sense  of  resistance  is  ex])erienced  by  the  pleximeter 
tinger.  In  pleurisy  with  effusion  the  upper  limit  of 
the  fluid  generally  follows  a  curved  line,  as  is  shown 
in  the  accompanying  figures  (Figs.  67,  68,  69). 

In  the  case  of  patches  of  solid  lung  substance,  the 
airless  j)ortion  is  often  surrounded  by  a  shell  of  tissue 
in  which  the  septa  are  relaxed.  The  result  of  per- 
cussion over  this  composite  arrangement  is  to  produce 
a  sound  whose  resonance  is  less  intense  and  emptier 
than  the  healthy  lung  would  yield,  whilst  what  is  left 
of  it  assumes  a  subtympanitic  quality.  The  effect  is 
described  as  a  boxy  or  wooden  sound. 

Several  peculiar  sounds  which  are  produced  by 
percussion  in  pathological  conditions  remain  to  be 
noted. 

4Jracked-|>ot  sound. — This  is  due  to  a  sudden 
expulsion  of  air  through  a  constricted  orifice  It 
occurs  in  cases  where  percussion  is  practised  over 
a  cavity  which  communicates  with  a  bronchus  of 
moderate  size,  and  is  most  distinct  when  the  mouth 
is  opened.  It  has  a  hissing  character,  combined  with 
a  chinking  sound  like  that  produced  by  shaking  coins 
together.  It  is  also  heard  in  certain  cases  of  thoracic 
fistula,  and  occasionally  in  pneumothorax,  as  well  as 
in  the  relaxed  lung  above  the  level  of  fluid  in  })leurisy, 
and  near  the  consolidated  area  in  pneumonia.  If 
healthy  children  are  percussed  whilst  they  are  crying, 
a  cracked-pot  sound  is  often  produced. 


Percussion.  239 

Aiii|>liori€  resonance.  —  This  phenomenon 
is  clue  to  the  selective  reinforcement  of  certain 
vibrations  by  a  large  cavity ;  by  this  means 
the  overtones  are  accentuated  and  die  out  more 
slowly. 

The  following  alterations  in  percussion  sounds 
may  be  observed  under  certain  pathological  con- 
ditions ;  their  explanation  is  for  the  most  part  simple 
from  a  physical  standpoint. 

(a)  Tympanitic  resonance,  when  due  to  the 
presence  of  a  pulmonary  cavity  which  communicates 
with  a  bronchus,  is  raised  in  pitch  when  the  patient 
opens  his  mouth.  This  is  sometimes  called  Wintrieli's 
phenomenon. 

{b)  The  pitch  of  the  percussion  sound  over  a 
cavity  varies  with  the  position  of  the  patient.  The 
most  obvious  explanation  is  that,  if  the  cavity  be 
partly  filled  with  fluid,  this  varies  in  position  and  so 
alters  the  shape  of  the  cavity  when  the  patient 
changes  his  attitude.  Other  factors,  however,  often 
enter  into  the  interpretation  of  this  change,  which  has 
been  called  Oerliardt's  phenomenon. 

(c)  The  resonance  over  a  cavity  becomes  higher 
in  pitch  during  inspiration,  and  lower  during  expira- 
tion. The  phenomenon  depends  on  the  tension  of 
the  cavity,  and  is  called  Friedreich's  pheno- 
menon. 

(d)  In  pneumothorax  the  metallic  resonance  is 
higher  in  pitch  when  the  patient  is  lying  dow^n  than 
when  he  sits  up.  This  is  referred  to  as  Biermei^'s 
phenomenon. 

In  certain  conditions  of  malnutrition  the  muscles 
on  the  front  of  the  thorax  are  unduly  irritable.  In 
these  circumstances  a  light  tap  over  the  sternum  pro- 
duces fibrillary  contractions  at  some  distance  off,  in 
the  pectoral  muscles:  This  phenomenon  often  occurs 
in  phthisis. 


240 


Respir  a  tor  y  Svs  tem. 


SECTION  v.— AUSCULTATION. 

Auscultation  determines  : — ■ 

A.  Character  of  respiratory  sounds. 

l' Normal. 

Fue.ile. 
Harsh. 

Jerky  or  cog-wheel. 
Feeble  or  absent. 
With  prolonged  expiratory 
murmur. 
'^  I  Low-pitched  (cavernous). 
I.  .S  {  Medium-pitched. 

^  (  High-pitched  (tubular). 

Amphoric   i  Low-pitched, 
(with  an  echoing  <  Medium-pitched, 
quality  added)       (  High-pitched, 
(c)  Indeterminate  or  broncho-vesicular  breathing. 

B.  Vocal  resonance. 

I  Slight. 

Increase     <  Marked,  Bronchophony. 
(  Extreme,  Pectoriloquy. 

Slight. 
Decrease    \  Marked. 

Entire  absence. 


(«)  Vesicular        breathing  , 
(rustling  in  character) 


{h)  Bronchial  breath- 
ing (guttural  [ch] 
or  aspirate  [ha] 
in  character) 

ir. 


{a)  Quantitative 
changes 


I  Aegophony. 

\  Amphoric  resonance. 


Mcdii 


[b')  Qualitative  changes 

C.  Accompaniments. 

p  ,  ^  (  Sibilant  or  high-pitched. 

iWn    '  ''h'\   I  -^Isdl^'^'Ti -pitched. 
^  ^  ^/  (  Sonorous  or  low-pitched. 

(«)  Rales ^  fIiesotu(Jit(-aietal\ic)'\   /Fine. 

Moist(Cre-  J      or  consonant 
pitations)  |  Non-resonant       or 

y     toneless  )   \  Coarse. 

[b)  Friction  sounds. — Fine,  medium,  coarse. 

[c]  Splashing  sounds. — (Hippocratic  succussion). 

In  auscultation  three  observations  must  be  made 
at  each  point  examined  :  First,  the  cliaracter  of  the 
breath  sounds  j    second,  the   character   of   the   vocal 


A  use  UL  TA  TION.  2  4  I 

resonance;  and  third,  the  presence  or  absence  of  other 
sounds. 

In  ord(!r  to  make  these  observations  with  facility, 
the  examiner  should  attend  to  the  attitude  of  the 
patient,  which  must  be  as  symmetrical  and  uncon- 
strained as  circumstances  will  permit.  This  is  easily 
attained  when  the  patient  can  sit  up  ;  but  if  he  is 
unable  to  do  this  he  should  be  rolled  round  first  to 
one  side  and  then  to  the  other,  in  order  that  the  back, 
and  especially  the  bases  of  the  lungs,  may  be  thor- 
oughly examined.  The  student  must  remember  that 
in  serious  cases  great  injury  may  be  done  to  a  patient 
by  too  prolonged  an  examination.  Care  must  be 
taken,  especially  when  an  ordinary  single  stethoscope 
is  used,  that  the  chest-piece  is  accurately  applied,  and 
that  no  undue  pressure  is  exerted.  The  patient  must 
be  directed  to  breathe  through  the  nose,  regularly 
and  fairly  deepl}',  but  not  noisily. 

There  are  two  typical  varieties  of  breath  sound, 
both  of  which  are  audible  in  health  at  certain  parts 
of  the  chest,  and  these  must  be  carefully  studied. 
The  first  is  known  as  vesicular  breathing,  the  second 
as  bronchial.  The  former  is  heard  over  healthy  lung 
tissue,  the  latter  over  the  trachea  and  main  bronchi. 

In  vesicular  breathing:,  which  can  be  heard 
typically  in  the  axillary  and  infrascapular  regions 
of  a  healthy  individual,  the  following  facts  will  be 
noted  : — 

The  inspiratory  sound  is  fairly  intense,  and  is 
audible  during  the  whole  of  the  act.  The  pitch  is 
low  and  the  quality  is  characteristic,  being  some- 
what rustling.  It  is  this  quality  which  is  specially 
described  as  vesicular. 

The  expiratory  sound  follows  that  of  inspiration 
without  a  distinct  pause — ^unless,  as  not  infrequently 
happens,  the  patient  holds  his  breath  for  a  second  at 
the  end  of  inspiration — it    is    less  intense   than  the 

Q 


242  Respiratory  System. 

inspiratory  sound,  is  lower  in  pitch,  and  lacks  tlie 
vesicular  quality,  being  more  of  a  simple  Ijlowing 
sound.  It  only  remains  audible  during  the  earlier 
part  of  the  expiratory  phase,  and  under  normal  con- 
ditions the  inspiratory  sound  is  heard  for  at  least 
thrice  as  long  a  time  as  the  expiratory. 

To  learn  to  recognise  bronchial  breathing, 
the  student  should  listen  over  the  trachea,  though 
he  must  not  expect  to  hear  so  intense  a  type  of 
bronchial  respiration  when  he  subsequently  examines 
a  diseased  lung. 

The  inspiration  sound  is  moderately  intense. 
It  becomes  inaudible  shortly  before  the  end  of  in- 
spiration. Its  pitch  is  much  higher  than  that  of 
vesicular  breathing,  and  the  quality  is  blowing  or 
hollow,  with  a  guttural  or  aspirate  intonation. 

The  expiration  sound  is  generally  more  intense 
than  the  inspiratory ;  the  pitch  is  often  higher ;  the 
duration  extends  through  the  greater  part  of  expira- 
tion, being  as  long  as,  or  even  longer  than,  the 
inspiratory  sound,  from  which  it  is  divided  by  the 
silent  period  that  marks  the  end  of  inspiration.  In 
quality  it  exactly  resembles  the  inspiratory  sound, 
being  aspirate  or  guttural  in  character.  This  quality 
is  sometimes  described  as  "  tubular,"  but  the  same 
name  is  also  applied  to  one  of  the  varieties  of 
bronchial  breathing,  and  so  is  better  avoided. 

The  principal  variations  which  can  be  detected 
in  vesicular  breathing'  are  as  follows  : — 

1.  Puerile. — The  sounds  are  harsher  than  in 
the  adult,  but  have  a  similar  duration. 

2.  Harsh,  with  prolongation  of  expiration,  the 
character,  however,  remaining  vesicular.  This  fre- 
quently indicates  loss  of  elasticity  of  lung  tissue; 
hence  it  often  occurs  in  early  phthisis,  but  may  occur 
in  bronchitis. 


A  use UL  TA  TION.  1^% 

3.  Jerky,     iiitorriiptod,     or     '"  <*oj;:\vIi<M'I  '' 

iiispirsilioii. — Here  the  sound  is  not  continuous, 
but  occurs  in  waves  or  sharp  jerks.  This  indicates 
irreguhir  ex[)ansion  of  the  alveoli,  due  to  unequal 
elasticity  in  various  parts  of  the  lobules,  and  is 
therefore  not  infrequently  present  in  early  phthisis. 
It  may  also  result,  however,  simply  from  nervousness, 
and  to  carry  any  weight  as  a  physical  sign  it  must  be 
Avell  marked  even  on  deep  inspiration.  Even  then, 
however,  it  may  mean  little  or  nothing,  and  should 
only  take  a  very  secondary  place. 

4.  Tlie  respiratory  niiiriiiiir  laiay  be 
feeble,  or  even  inaudible.  In  quiet  breathing  the 
expiratory  sound  is  often  quite  absent.  By  making 
the  patient  breathe  more  deeply  the  murmur  may 
be  rendered  audible.  When  marked,  this  condition 
may   indicate    defective    expansion. 

Total  disappeai  aiice  of  tlie  breath 
sounds  occurs  below  the  level  of  fluid  in  pleuritic 
exudation  because  the  relaxed  lung  does  not  conduct 
sounds  well,  and  hence  they  are  not  conveyed  to 
the  fluid,  which  is  itself  a  comparatively  good  con- 
ductor (see  p.  255).  If,  however,  there  be  only  a 
small  quantity  of  fluid  present,  the  sounds  may  be 
faintly  heard  as  the  relaxation  of  the  lung  tissue  is 
less  pronounced. 

With  regard  to  jwolongation  of  the  expiratory 
sound,  it  must  be  recollected  that  in  certain  diseases, 
such  as  emphysema  and  asthma,  the  expiratory  act 
is  performed  much  more  slowly  than  in  health. 
In  consequence  of  this,  the  respiratory  sound  may 
also  be  prolonged  ;  hence  in  these  diseases  prolon- 
gation of  expiration  conveys  a  different  meaning 
than  usual. 

Some  patients  are  habitually  shallow  breathers, 
whilst  others  naturally  breathe  deeply.  The  ear  can 
detect   these    variations    partly    by    the    duration    of 


244  Respiratory  System. 

the  respiratory  sounds,  and  partly  by  their  intensity. 
The  depth  of  Ijreathing  as  estimated  by  auscultation 
is  sometimes  known  as  the  **  respiratory  excur- 
sion." 

Bronchial  breatliing*  may  be  subdivided  into 
three  varieties,  according  as  the  laryngeal  respiratory 
sound  is  conveyed  to  the  ear  through  consolidated 
lung  from  the  larger,  medium,  or  smaller  air- passages, 
each  of  which,  by  reinforcing  certain  elements  of 
that  sound,  give  it  a  distinctive  character. 

In  the  first  case  we  have  low-pitched 
bronchial  breathing',  the  more  capacious  tubes 
responding  best  to  the  deeper-toned  elements  of  the 
laryngeal  murmur  ;  in  the  second  case  the  pitch  is 
medium ;  in  the  last  it  is  high.  Low-pitched 
bronchial  breathing  is  heard  pathologically  over 
moderately  large  cavities  in  the  lungs,  and  is  hence 
sometimes  called  cavernous ;  high-pitched  bronchial 
breathing  is  heard  when  consolidation  has  occurred 
round  the  smaller  tubes,  as  in  pneumonia,  where  the 
most  perfect  examples  of  bronchial  breathing  may 
often  be  found.  Here  the  character  is  aspirate 
rather  than  guttural.  This  variety  is  also  known  as 
tubular  breathing. 

A  special  variety  of  bronchial  breathing  exists 
under  diseased  conditions,  and  is  known  as  amphoric 
respiration.  It  resembles  the  sound  produced  by 
blowing  across  the  mouth  of  a  bottle  or  the  muzzle  of 
a  gun.  The  sound,  when  analysed,  is  found  to  consist 
of  one  or  more  low-pitched  fundamental  tones  and 
a  number  of  high-pitched  overtones.  It  is  char- 
acteristic of  a  direct  communication  between  a 
bronchus  and  either  a  considerable  cavity  with  fairly 
smooth  walls  or  a  pneumothorax.  The  latter  con- 
dition yields  the  best  examples. 

In  cases  where  the  resonance  of  a  bronchus  is 
within    earshot    of   the    observer,    but  where  at   the 


A  USCUL  TA  TION.  245 

same  time  air-containing  lung  intervenes  between 
the  bronchus  and  the  chest  wall,  tlie  sound  of  the 
l)reathing  combines  both  vesicular  and  bronchial 
elements,  one  or  other  type  predominating  according 
to  the  exact  relations  in  each  case.  This  variety 
of  breath  sound  is  known  as  bronclio-vcsicular 
or  iiideteriuiiiatc.  It  occurs  in  health  in  certain 
regions  where  anatomical  causes  favour  its  pro- 
duction, especially  near  the  roots  of  the  lungs  behind, 
and  in  the  upper  portions  near  the  middle  line  in 
front.  The  resonance  of  bronchi  which  lie  so  deeply 
in  the  chest  as  to  be  completely  muffled  by  the 
thick  layer  of  lung  tissue  that  separates  them  from 
the  ear  may  become  audible  when  the  tissue  around 
them  becomes  solidified,  and  thus  conducts  the  sounds 
more  effectively.  If  the  consolidation  reach  to  the 
surface  of  the  lung  the  breathing  will  be  bronchial, 
but  if  it  does  not  extend  so  far,  bronchial  breath- 
ing will  be  heard  through  the  vesicular  breathing 
which  is  still  being  produced  between  it  and  the 
surface. 

The  breath  sounds  must  be  auscultated  in  the 
various  regions  that  have  already  been  examined  by 
percussion,  their  character  in  each  noted,  and  similar 
regions  on  the  two  sides  of  the  chest  compared ;  care 
being  taken  that  the  points  examined  correspond 
accurately  to  one  another. 

The  second  series  of  observations  is  directed  to 
the  intensity  and  character  of  th«i  vocal 
resonance.  It  varies  in  intensity  even  in  health 
on  the  two  sides  and  over  different  areas  of  the  lung, 
beino[  louder  on  the  right  side  and  more  intense  the 
nearer  the  stethoscope  is  to  the  larger  bronchi.  When 
the  patient  repeats  the  words  "  one,  one,  one,"  or 
"ninety-nine,"  the  ear  receives  from  the  chest  no 
distinct  impression  of  tlie  syllables  pronounced,  but 
only  a  buzzing  sound,  whose  intensity  depends  on  the 


246  Respiratory  SvsTEAr. 

loudness  and  depth  of  the  patient's  voice  and  on  the 
conductivity  of  his  lungs.  Other  words  or  sentences 
may  be  used  instead  of  the  above,  but,  on  the  whole, 
these  are  well  adapted  to  jjroduce  satisfactory  and 
uniform  vibration  of  the  chest,  and  are  therefore 
suitable  for  the  purpose  of  comparing  different  points 
with  one  another. 

An  easy  way  of  keeping  a  standard  of  intensity  in 
the  mind  when  examining  is  to  conceive  of  the  sound 
taking  rise  at  different  distances  from  the  observing 
ear."^  In  some  cases  the  sound  is  very  distant.  This 
is  equivalent  to  "  marked  decrease  "  in  vocal  resonance. 
Sometimes  the  sound  appears  to  be  produced  at  a 
little  distance  from  the  chest-piece  of  the  stethoscope. 
In  this  case  the  resonance  is  sliglitl}^  decreased, 
and,  to  make  certain  of  this,  a  comparison  shoukl 
at  once  be  made  with  the  corresponding  point  over 
the  other  lung.  In  fact,  as  in  percussion  and  pal- 
pation, so  in  estimating  resonance  —  each  point 
examined  on  one  side  of  the  chest  should  be  at  once 
compared  with  the  corresponding  point  on  the  other 
side. 

Yocal  resonance  of  normal  intensity  generally 
conveys  the  impression  of  being  produced  just  at  the 
chest-piece  of  a  single  stethoscope.  If  it  seems  to  be 
nearer  the  ear  than  this,  the  resonance  is  increased. 
When  it  is  near  the  ear-piece  of  the  stethoscope,  the 
increase  is  ''  marked,"  and  the  condition  is  often 
described  as  broiicliophoMy. 

If  the  words  become  articulate  and  seem  to  be 
spoken  right  into  the  auscultator's  ear,  it  will  generally 
be  found  that  even  whispered  words  are  clearly  heard. 
This   condition  is   called  pectoriloqtiy.     Increased 

*  The  same  method  is  to  some  extent  applicable  to  the  ex- 
amination of  breath  sounds.  It  is  rather  arliitrary,  as  it  does  not 
take  account  of  the  differences  which  are  normally  found  in 
different  areas  of  the  chest ;  still  it  is  serviceable,  especially  for 
besiniiers. 


Auscultation.  247 

resonance  occurs  wlien,  throngli  any  cause,  tlic  lung 
substance  conducts  the  sound  waves  set  up  by  the 
voice  more  clearly  than  usual  from  the  bronchi.  Con- 
solidation is  the  commonest  cause  of  increased  lung 
conducti\'ity.  Bronchophony  occurs  when  a  moderately 
large  bronchus  is  surrounded  by  a  layer  of  solid  lung 
reaching  to  the  chest  wall.  Pectoriloquy  is  fairly 
characteristic  of  a  cavity  of  some  size  communicating 
with  a  bronchus.  Cases  do,  however,  occur  where  a 
certain  degree  of  pectoi'iloquy  is  heard  over  the  front 
of  the  upper  lobe  of  the  lung  when  the  lower  lobe  is 
com[)ressed,  as,  for  instance,  by  pleuritic  effusion.  Care 
must  be  taken  that  the  articulate  sounds  do  not  reach 
the  observer  either  through  the  other  ear  or  by  the 
patient's  lips  being  directed  towards  the  stem  or  ear 
piece  of  the  stethoscope. 

For  reasons  already  explained,  vocal  resonance  is 
either  entirely  abolished  or  much  diminished  where 
a  layer  of  fluid  separates  the  lung  from  the  chest 
wall  (see  p.  243).  It  is  also  diminished  in  cases 
of  thickened  pleura,  and  of  emphysema. 

Under  certain  conditions  the  quality  of  the  vocal 
resonance  undergoes  modification.  Pectoriloquy  has 
already  offered  us  an  example  of  such  a  modification, 
but  a  noticeable  change  also  occurs  in  pneumothorax, 
when  an  aiBsplioric  or  metallic  echoiiag-  reso- 
nance is  imparted  to  the  voice,  as  well  as  to  the 
breath  and  heart  sounds.  Another  alteration  in  the 
quality  of  the  vocal  resonance  is  observed  in  some 
cases  of  pleurisy.  "When  the  quantity  of  effusion  is 
rather  scanty,  so  that  the  lung  is  only  separated  from 
the  chest  wall  by  a  thin  layer  of  fluid,  a  nasal  or 
bleating  character  may  be  imparted  to  the  voice. 
This  bleating  tone  is  observed  much  more  frequently 
at  the  back,  near  the  lower  angle  of  the  scapula  or 
between  that  point  and  the  axillary  line,  than  it  is 
over  other  regions  of  the  thorax.     It  is  known  as 


248  RESPfRATORY   SVSTEM. 

SBg^ophoiiy,  and  is  probably  clue  to  collapse  of  the 
bronchial  tubes. "^ 

The  last  series  of  observations  is  directed  to  the 
detection  and  recognition  of  various  adventitious 
sounds. 

These  may  arise  either  in  the  lungs  or  in  the 
pleura,  and  it  must  never  be  forgotten  that  sounds 
by  no  means  very  dissimilar  may  be  produced  by  the 
friction  of  the  stethoscope  on  a  hairy  chest  wall ;  but 
the  latter  can  usually  be  suppressed  by  moistening 
the  skin.  The  accompaniments  arising  in  the  lung 
and  bronchi  themselves  first  demand  attention. 

^  Such  accompaniments  are  collectively  known  as 
rales,  and  are  subdivided  into  dry  rales  and  moist 
rales.  Dry  sounds,  known  also  as  rhonclii,  are 
produced  in  the  air-passages,  and  are  due  to  partial 
obstruction  of  their  lumen  either  by  swelling  of  the 
mucosa  or  by  the  presence  of  tough  secretion.  The 
mechanism  of  their  production  is  thus  comparable  with 
that  to  which  cardiac  murmurs  owe  their  existence. 

They  vary  in  pitch,  the  variations  being  in  a  great 
measure  due  to  the  size  of  the  tubes  where  they  take 
origin.  The  smaller  tubes  are  the  seat  of  high-pitched 
or  sibilant  rlionciii,  and  these  are  most  abundant 
during  the  later  part  of  inspiration ;  the  medium-sized 
tubes  yield  medium-pitched  rhonchi,  and  the  larger 
bronchi  produce  the  deep-toned  or  sonorous 
rhonchi,  which  are  heard  early  in  inspiration,  and 
may  be  almost  continuous.  Dry  sounds  are  charac- 
teristic of  bronchitis,  but  are  also  found  quite  apart 
from  any  definite  bronchitis  in  certain  other  diseases 
of  the  respiratory  system,  such  as  cases  of  phthisis 
when  the  bronchial  tubes  get  plugged. 

*  Dr.  Stone  (quoted  in  Fagge's  "Principles  and  Practice  of 
"  Medicine, "  .3rd  ed.,   vol.   i.,  p.  940)   considers  that   the  peculiar 
quality  of  the  voice  is   due   to  the  fundamental  tone  being  in- 
tercepted by  the  effusion  to    a   much    greater   degree   tlian  the 
over-tones,  which  thereby  become  unduly  conspicuous. 


A  USCUL  TA  TION.  2  49 

HloiHt  rales,  also  called  cre|>ita1ioii$,  are  pro- 
duced either  in  the  alveoli  or  in  the  bronchioles  and 
bronchi.  They  produce  on  the  ear  a  sound  like  the 
bursting  of  smaller  or  larger  air- bubbles,  and  indicate 
the  presence  of  fluid  secretion  in  the  air  cells  or  tubes. 
They  are  classitied  as  fine,  medium,  and  coarse  or 
bubblino^.^ 

Fine  erepitataoiis  are  caused  by  the  opening 
up  of  collapsed  alveoli  whose  walls  have  been  agglu- 
tinated by  the  exudation  of  a  little  fluid  secretion. 
This  at  first  causes  them  to  adhere,  but,  as  the  air 
pressure  gradually  increases  during  the  movement  of 
inspiration,  the  adhesion  at  last  gives  way  suddenly, 
and  allows  air  to  enter.  The  separation  of  the  walls 
is  accompanied  by  a  cracking  sound,  which  can  be 
imitated  by  separating  the  moistened  forefinger  and 
thumb  near  the  ear.  When  this  condition  occurs  in  a 
number  of  alveoli,  the  combined  eflect  is  to  produce 
the  sound  of  fine  crepitation.  It  occurs  onlyf  near 
the  end  of  inspiration,  as  is  to  be  anticipated  from  its 
mode  of  production,  and  indicates  the  presence  of 
exudation  in  the  alveoli  of  the  affected  part  of  the  lung. 
Fine  crepitations  are  veiy  characteristically  present 
during  the  first  stage  of  pneumonia,  and  in  acute  con- 
gestion from  any  cause  ;  they  also  occur  in  early  miliary 
tuberculosis.  After  atelectasis  they  are  occasionally 
heard,  and  in  oedema  of  the  lung  they  occur  in  asso- 
ciation with  bubbling  rales  which  are  caused  by  the 
simultaneous  presence  of  fluid  in  the  bronchi. 

Meclitiiii  crepitations  occur  chiefly  in  the 
smaller  bronchi,  and  are  audible  at  the  end  of  in- 
spiration and  the  beginning  of  expiration.  They  are 
caused  by   the  air   bubbling  through    fluid   secretion 

*  The  term  "  crepitation  "  is  sometimes  restricted  to  the  first 
variety,  the  others  being  called  fine  and  coarse  bubbling  rales. 

t  Rarely  a  few  sounds  closeh'  resembling  fine  crepitations  are 
heard  during  expiration. 


250  Respiratory  System. 

which   has   been  poured  out   into  the   hunen   of  the 
bronchi. 

Coarse  bubbling  crepitations  occur  in  the 
larger  divisions  of  the  bronchi,  and  may  be  heard  at 
almost  any  phase  of  respiration ;  they  may  be  quite 
continuous  in  their  occurrence.  Coarse  crepitations 
may  also  originate  in  pulmonary  cavities. 

Sometimes  the  rales  are  11011-resoiiaDit  or 
toneless.  In  this  case  they  occur,  as  a  rule,  in 
spongy  lung  tissue ;  but  in  other  cases  they  are  quite 
resonant,  and  convey  an  impression  to  the  ear  of 
being  all  possessed  of  a  definite  pitch.  There  are 
only  two  conditions  in  which  resonant  rales  occur — 
either  consolidation  exists,  or  there  is  a  cavity  of 
sufficient  size  to  act  as  a  resonator  for  rales  which  ire 
produced  either  in  itself  or  in  a  neighbouring 
bronchus. 

The  highest  degrees  of  resonance  are  known  as 
metallic  and  tinkling^  consonances.  Here 
the  rales  have  a  very  distinct  high  pitch,  and  give  the 
impression  of  a  shower  of  drops  falling  into  a  metallic 
vessel,  which  reverberates  the  sound  of  their  fall.  This 
is  associated  with  amphoric  breathing,  and,  like  it, 
suggests  either  a  large  cavity  or  pneumothorax. 

The  position  where  rales  are  heard  greatly  influ- 
ences the  importance  to  be  attached  to  their  presence. 
If  heard  at  the  apex,  they  at  once  suggest  phthisis; 
whilst  medium  and  coartie  crepitation  at  the  bases 
may  be  due  merely  to  a  transient  exudation  which 
will  rapidly  disappear  again.  When  the  patient  has 
been  breathing  quietly  for  some  hours,  and  especially 
if  he  has  been  lying  in  bed,  a  few  crepitations,  even  if 
heard  at  the  apex,  may  be  due  to  temporary  causes, 
though  they  should  always  be  regarded  with  a  degree 
of  suspicion. 

The  commonest  accompaniment  arising  in  the 
pleural  cavity  is  a  friction  -sound  characteristic  of 


Auscultation: 


251 


pleurisy  :it  the  stage  wliere  exudation  is  not  abundant 
enough  to  separate  the  inflamed  and  roughened  sur- 
faces.     It  possesses  a  creaking  or  rubbing  character, 
often  quite  characteristic ;  but  sometimes,  when  less 
well  marked,  rather  hard  to  distinguish  from  a  rale. 
The  friction  sound  may  be  fine,  medium,  or  coarse.     In 
some  instances  it  is  palpable,  but,  since  coarse  rales 
may  be  so  too,  this  does  not  serve  to  distinguish  them. 
The  chief  features  of  difference  are  that  friction 
sounds  occur  during  that  part  of  inspiration  when  the 
roughened  surfaces  are  rubbing  against  each  other,  to 
reappear  at  a  corresponding  period  of  expiration.    They 
are,  moreover,  unchanged  after  the  patient  has  coughed, 
whilst  rales  may  alter  under  these  conditions  because 
of  changes  in  the  disposition  of  the  secretion   which 
causes    them.     The    fact    that    friction   is   sometimes 
more  localised  than  crepitation  may  also  be  of  service. 
Sometimes  friction  is  markedly  intensified  by  increas- 
ing the  pressure  with  which  the  stethoscope  is  applied. 
This  acts   by  causing  the   roughened  surfaces  to  rub 
against   each   other  more  firmly.     Pressure   does  not 
affect   the  intensity   of    rales.      The   situation  of  the 
doubtful  sound,  or  the  presence  of  pain,  or  some  point 
in  the  history  of  the  case,  may  assist  the  observer  in 
arriving  at  the  diagnosis. 

It  must  never  be  forgotten  that  the  presence  of 
one  form  of  accompaniment  does  not  exclude  the 
others.  Any  two  or  all  three  may  be  found  co- 
existing in  one  case.  When  pleuritic  friction  is 
developed  along  the  anterior  edge  of  the  left  lung, 
and  especially  when  that  part  of  it  which  is  in  rela- 
tion to  the  apical  segment  of  the  heart  is  affected, 
the  friction  sounds  often  assume  the  rhythm  of  the 
heart-beat  rather  than  that  of  the  respiratory  move- 
ments. Hence  the  sound  is  liable  to  be  mistaken 
for  pericardial  friction.  To  distinguish  between  this 
so-called  pJew-Q'perimrdial  friction  and  that  of  true 


252  Respiratory  System. 

pericarditis  will  rarely  be  very  difficult  if  it  is  recol- 
lected that  the  former,  depending  as  it  does  on  the 
apposition  of  two  roughened  patches  of  pleura,  is  only 
heard  during  those  phases  of  respiration  when  the 
patches  are  in  contact.  Hence  a  deep  inspiration,  by 
removing  one  of  them  from  the  other  may  prevent 
the  production  of  the  sound,  whilst  in  other  cases 
holding  the  breath,  or  emptying  the  lungs  as  com- 
pletely as  possible  may  lead  to  a  like  result.  In  short, 
pleuro-pericardial  friction  is  much  more  dependent 
than  true  pericardial  friction  on  the  movements  of 
respiration. 

Hippocratic  succussioii  is  the  name  given  to 
a  splashing  sound  which  can  be  heard  when  a  patient 
who  has  both  gas  and  fluid  (usually  pus)  in  the  pleural 
cavity  is  shaken  or  moves  suddenly. 

SECTION    VI.— SYMPTOMS    OF    THE    PRIN- 
CIPAL PULMONARY  DISEASES. 

1.  Acute  bronchitis. — The  patient  complains 
,of  pain  behind  the  sternum,  of  some  breathlessness, 
and  of  troublesome  cough.  The  sputum  is  at  first 
mucous  and  scanty,  but  subsequently  becomes  muco- 
purulent and  abundant.  The  physical  signs  are,  by 
percussion,  resonance  normal ;  by  auscultation,  breath 
sounds  vesicular,  and  accompanied  by  sonorous  and 
sibilant  rhonchi,  the  latter  being  especially  prominent 
when  the  smaller  tubes  are  implicated.  The  vocal 
resonance  is  unaltered. 

2.  Chronic  bronchitis, — The  symptoms  re- 
semble those  of  acute  bronchitis,  but  pain  is  less,  and 
dvspnoea  is  more  marked.  The  sputum  is  abundant 
and  mucopurulent.  Coarse  crepitations  are  usually 
abundant. 

3.  t^niphysenia. — The  patient  suffers  from 
breathlessness,  and  is  often  somewhat  cyanosed.     He 


Symptoms  of  Pulmonary  Diseases.      253 

generally  has  a  good  deal  of  cough  and  some  expec- 
toration. Tlie  chest  is  barrel-sliaped,  and  its  expan- 
sion during  inspiration  is  insufficient.  On  percussion 
there  is  hyper-resonance,  sometimes  a  trace  of  tym- 
panicity.  The  borders  of  the  lungs  encroach  on 
sui'rounding  organs,  and  the  area  of  superficial  cardiac 
dulness  may  he  greatly  lessened.  Auscultation  reveals 
prolongation  of  expiration  and  diminution  of  vocal 
resonance. 

■t.  Phtliisis. — The  earliest  signs  of  the  disease 
are  often  loss  of  weight  and  appetite,  cough,  and 
tendency  to  sweating  during  the  night.  At  a  later 
stage  one  finds  severe  cough,  especially  in  the  morning, 
sometimes  hemoptysis,  increased  rate  of  respiration, 
diarrhcea,  hectic  fever,  and  the  other  symptoms  of  an 
acute  inflammatory  disease.  Inspection  reveals  in 
many  cases  a  phthinoid  chest  with  local  retraction 
and  defective  movement.  By  palpation  one  detects 
increased  vocal  fremitus ;  by  percussion,  localised 
dulness,  especially  above  or  below  the  clavicle,  and 
sometimes  the  physical  signs  of  a  cavity  are  apparent. 
By  auscultation  one  finds  that  expiration  is  prolonged, 
or  that  the  breathing  is  bronchial  in  character.  The 
breath  sounds  are  accompanied  by  crepitations,  most 
of  which  are  of  medium  size.  The  sputum  contains 
tubercle  bacilli,  and  often  also  elastic  tissue. 

5.  LrOtoar  pueumooia  is  recognised  by  its 
sudden  onset  with  rigors,  cough,  and  pain  in  the 
side,  associated  with  fever  which  remains  continu- 
ously high.  The  face  is  flushed,  the  breathing  rapid, 
and  the  sputum,  which  is  not  copious,  is  rust- 
coloured  and  excessively  tenacious.  The  microscope 
reveals  the  presence  of  pneumococci.  The  physical 
signs  vary  with  the  stage  of  the  disea-se.  First  stage  : 
Percussion-sound  rather  tympanitic  but  slightly  dull, 
fine  crepitations  present.  Second  stage  :  Absolute  dul- 
ness on  percussion,  high-pitched  bronchial  breathing, 


254 


ReSPJR a  TORY   S} 'S TEM. 


increased  vocal  resonance  and  fremitus.  Third  stage  \ 
Gradual  diminution  of  dulness,  disappearance  of 
bronchial  breathing,  presence  of  medium  and  some 
fine  crepitations.  Vocal  resonance  and  fremitus 
return  to  normal  (Fig.  70). 

6.  Chronic  interistitial  piiciinionia. — The 
patient  complains  of  some  breathlessness  on  exertion, 
and  of  cough  with  rather  copious  nmcopurulent 
expectoration.  The  sputum  may  be  fetid,  or,  when 
the  disease  is  a  pneumonokoniosis,  may  contain 
characteristic    elements.     The    physical    signs    are    a 

•_/i  Oilixf^'        ,..,  Marked i'eci/PesonsacB 


|r.<:<-«fr:?l/<,«" 


Ca/Zed  BronaJTophan/ 


Fig.  70. — Physical  signs  at  beginning,  height  and  decline  of  a  pneumonia. 

i^AfUr  Wyllie.) 

gradually  developed  flattening  over  the  affected 
region,  where  also  expansion  is  absent,  or  defective 
and  delayed ;  die  shoulder  of  the  diseased  side  droops. 
On  percussion  there  is  a  dull  area  surrounded  by  one 
where  the  resonance  is  boxy,  and  the  heart  is  drawn 
over  by  the  contracted  lung.  Auscultation  reveals 
feeble  or  bronchial  breathing,  and  a  few  crepitations 
and  rhonchi.  The  vocal  resonance  and  fremitus  are 
exaggerated. 

7.  Pleurisy  is  characterised  by  the  presence  of 
fever,  pain  in  the  side,  restrained  but  rapid  breathing, 
and  suppressed  dry  cough.     In  early  stages  friction  is 


Syj/PTOMs  OF  Pulmonary  Diseases.      255 

aiidil)le,  whilst  ;iftor  etfusion  lias  occurred  one  nnds 
absolute  dulness  in  the  affected  area,  with  some  tym- 
panitic resonance  above  the  fluid.  Breath  sounds 
and  vocal  resonajice  are  diminished  or  absent  in  the 
dull  area.  Above  it  the  breathing  may  be  somewhat 
bronchial  and  accompanied  by  fine  crepitations.  En 
massive  effusions  the  neighbouring  organs  are  dis- 
placed (Fig.  71). 

8.  Paieuiiiotliorax. — The  patient  complains  of 
sudden  pain  and  breathlessness.  The  affected  side  is 
distended    and    immobile,    or   lags   behind   the   other. 


///7e  /^r/ct/o/i  Coarse  /^r/'ct/im 


Fig.  71.— Physical  signs  at  the  various  stages  of  pleurisy.     (After  Wyllie.) 

On  ])ercussion  there  is  a  loud,  deep  resonance  more  or 
less  tympanitic,  and  by  coin-percussion  a  characteristic 
ringing  sound  is  elicited.  The  breath  sounds  and 
vocal  resonance  are  absent,  or,  if  a  bronchus  com- 
municates with  the  pneumothorax,  are  replaced  by 
amphoric  breathing  and  resonance,  whilst  if  fluid  is 
present  one  may  hear  metallic  tinkling  and  elicit 
Hippocratic  succussion.  The  surrounding  viscera 
are  displaced. 

9.  Haeniorrliagic  infarction  of  the  lung 
occurs  in  the  course  of  valvular  heart  disease,  and  is 
characterised  by  the  sudden  onset  of  pain,  associated 
with  blood-stained  expectoration.  If  the  infarct  is 
near  an  accessible  portion  of  the  surface  of  the  lung, 


256  Respir  a  tor  y  Svs  tem. 

one  Cciii  often  discover  a  patch  of  dulness,  with  altered 
breath  sounds  and  crepitations. 

10.  AstBiuiii  may  usually  be  regarded  as  a  symp- 
tom rather  than  a  disease.  Cardiac  asthma  has 
already  been  described,  and  asthmatic  conditions 
may  likewise  arise  from  polypi  or  other  sources  of 
reflex  nasal  irritation,  or  from  disease  of  the  stomach 
or  kidneys.  The  form  known  as  bronchial  or  "  spas- 
modic "  asthma  results  mainly  from  spasm  of  the 
muscles  of  the  smaller  bronchi.  In  it  the  patient  is 
found  sitting  up  or  leaning  forward  with  the  hands 
fixed  on  some  object  in  order  to  give  additional  pur- 
chase to  the  accessory  muscles  of  respiration.  The 
face  is  flushed  and  the  vessels  are  turgid.  Expiration 
is  prolonged  and  laboured,  and  the  lungs  are  too  full 
of  air.  Percussion  yields  a  somewhat  hyper-resonant 
sound.  Auscultation  reveals  at  first  musical  rales 
and  wheezing  sounds,  with  marked  prolongation  of 
expiration.  After  secretion  has  been  established, 
deeper  rhonchi  become  audible.  The  sputum,  which 
is  scanty,  contains  small  lumps,  in  which  Cursch- 
mann's  spirals  and  Char  cot-Ley  den  crystals  are  found. 

SECTION   VII.— THE   SPUTUM. 

The  characters  of  the  cough  have  already  been 
treated  of  in  a  previous  chapter  (Chap.  II.).  It 
remains  to  add  a  few  notes  on  the  appearance  and 
examination  of  the  sputum  in  different  diseases.. 

The  following  are  the  principal  points  to  be 
observed  by  the  naked  eye  : — 

1.  Quantity  ; 

2.  Consistency  ; 

3.  Whether  homogeneous  or  in  layers  of  different 

apj)earance  ; 

4.  Whether  frothy  or  airless  ; 

5.  Colour  and  transparency  ; 

6.  Odour. 


The  Sputum.  257 

The  above  qualities  depend  on  the  character  of 
the  material  which  is  coughed  up.  The  main  varieties 
are  mucous  sputum,  serous  sputum,  fibrinous  spu- 
tum, purulent  sputum,  and  Ijlood.  In  many  instances 
transition  types  between  them  are  observed. 

Mucous  sputum  is  characteristically  present 
in  early  bronchitis.  It  is  clear,  tough,  and  stick}^ 
As  a  rule,  the  amount  is  not  great.  At  a  later  stage 
of  bronchitis  the  mucus  is  mixed  with  pus  cells.  The 
sputum  is  then  less  tough,  more  copious,  and  has  a 
greenish  yellow  colour. 

Muco-purulent  sputum  occurs  in  many  diseases 
of  the  lung.  In  phthisis  with  ca^dty  formation  one 
often  finds  small  ragged  lumps  of  muco-pus,  sur- 
rounded by  mucus,  which  are  heavier  than  the  other 
constituents  since  they  are  airless.  They  therefore 
sink  to  the  bottom  and  become  more  or  less  flat  and 
buttonlike.  This  constitutes  the  "nummular" 
sputum  of  phthisis.  If  there  be  a  fair  amount  of 
serous  or  watery  fluid  mixed  with  such  sputum  it 
gradually  settles  into  three  layers,  the  lowest  being 
purulent,  the  next  serous,  and  the  uppermost  com- 
posed of  frothy  mucus. 

Sputum  composed  of  pus  alone  usually  proceeds 
from  an  abscess  which  has  ruptured  into  the  lung  or 
air-passages. 

Serous  sputum  occurs  apart  from  mucous 
expectoration  as  a  thin  watery  fluid,  generally  blood- 
stained. It  indicates  cedema  of  the  lung.  Pulmonary 
cedema  without  extravasation  of  blood  yields  a  white 
frothy  sputum  like  soapy  water. 

Blood  may  be  coughed  up  alone,  or  the  sputum 
may  be  more  or  less  bloodstained.  It  must  be  dis- 
tinguished from  blood  brought  into  the  mouth  from 
epistaxis,  gastric  luemorrhage,  or  bleeding  from 
varicose  veins  in  the  walls  of  the  oesophagus.  Its 
brighter  colour  and  its  frothy  appearance  often  make 
R 


258  Respiratory  System. 

the  discrimination  perfectly  simple.  When  it  comes 
from  the  lungs  its  presence  may  result  either  from 
pulmonary  or  cardiac  disease,  or  from  aneurysm. 

Several  diseases  cause  a  characteristic  colora- 
tion of  the  sputum.  Thus,  in  pneumonia  it  is 
rusty  and  so  viscid  that  it  often  will  not  fall  out  of 
an  inverted  spittoon  ;  it  is  bright  yellow  or  g^reen 
when  a  liver  abscess  has  ruptured  into  the  lung,  and 
the  latter  colour  also  appears  in  some  cases  of 
pneumonia.  Sometimes  when  an  amoebic  hepatic 
abscess  has  discharged  by  the  lung,  the  sputum  has 
the  appearance  of  auchovy  sauce.  Black  spu- 
tum is  common  with  coal  miners,  whilst  red-streaked 
sputum  is  suggestive  of  phthisis.  Pruue-juice 
sputum  occurs  when  blood  lingers  in  a  lung  which 
has  become  oedematous.  Thus  it  is  found  in  cases  of 
chronic  pneumonia  that  are  going  on  to  disintegra- 
tion of  the  lung  tissue.  Red-currant-jelly  sputum 
is  said  to  be  characteristic  of  malignant  disease  in  the 
lung.     It  has  also  been  found  in  hysteria. 

The  quantity  of  sputum  coughed  up  in  twenty- 
four  hours  is  important ;  and  still  more  so  whether 
large  quantities  are  rapidly  got  rid  of  at  considerable 
intervals  or  whether  it  comes  away  in  small  amounts 
and  frequently. 

Occasionally  small  casts  of  bronchi  are  to  be 
found  in  the  sputum,  but  the  examination  for  formed 
elements  is  best  conducted  with  the  aid  of  a  microscope. 

The  odour  of  the  sputum  is  seldom  very 
characteristic.  Ordinarily  it  has  a  "  stale "  smell, 
but  in  cases  of  gangrene  of  the  lungs,  of  fetid  bron- 
chitis, and  of  bronchiectasis  it  may  develop  an 
exceedingly  penetrating  putrid  odour.  An  unpleasant 
odour  may  also  be  acquired  during  its  transit  through 
the  mouth. 

microscopic  examination  of  sputum. — 
Generally  it  is  well  first  to  examine  an  unstained  and 


The  Sputum.  259 

fresh  specimen,  and  thereafter  to  use  special  methods 
for  the  recognition  of  bacteria.  To  select  a  suitable 
piece,  place  the  sputum  in  a  Hat  glass  vessel,  which 
can  be  laid  on  either  a  white  or  a  black  backi^round 
as  is  found  convenient.  Mixed  with  the  amorphous 
mucous  exudation  which  forms  the  basis  of  the 
sputum  may  be  seen  various  organised  and  crystal- 
line substances,  of  which  the  following  are  the  principal 
groups  : — 

I.  Cellular  structures. — (1)  Pus  corpuscles 
in  various  stages  of  granular  degeneration  and  with 
several  nuclei. 

(2)  Epithelium  from  mouth,  air-passages,  and 
alveoli.  The  latter  may  contaiii  pigment  which  has 
reached  them  from  the  air,  or  they  may  exhibit  a  very 
characteristic  iron-containing  pigment,  which  is  un- 
usually abundant  in  cases  of  heart  disease  with  pul- 
monary congestion,  and  indicates  brown  induration 
of  the  lung.  This  pigment  yields  the  hsemosiderin 
reaction  on  the  addition  of  hydrochloric  acid  and 
potassium  ferro-cyanide. 

(.3)  Salivary  corpuscles  are  picked  up  by  the 
sputum  on  its  passage  through  the  mouth. 

(4)  Red  blood  corpuscles. — A  few  are  of  no 
importance.      Large  numbers  occur  in  haemoptysis. 

(0)  Eosiuophile  cells  occur  in  asthma,  and  are 
often  associated  with  Charcot-Leyden  crystals.  They 
are  large  and  contain  numerous  fine  granules  wbich 
stain  with  eosin. 

II.  Elastic  fibres  indicate  destruction  of  lung 
tissue,  whether  from  phthisis,  gangrene,  or  abscess. 
In  gangrene  only  a  few  fibres  escape  the  destructive 
process.  They  are  found  in  the  small  tough  lumps 
of  the  sputum,  and  are  best  demonstrated  by  a 
rapid  heating  with  an  equal  quantity  of  10  per 
cent,  solution  of  caustic  soda,  which  liquefies  the 
other  elements  more  quickly  than  these  fibres.     After 


26o 


Respiratory  System. 


boiling,   a   gelatinous   mass    is   left,  to  which   a  con- 


mm':- 


.,  i'^y'^         -^,  .....    .,-^  .^..  ^  - 


Fig.  72.— Elastic  tissue  from  lung  in  sputum  of  a  case  of  phthisis. 
X  300. 


siderable  quantity  of 
water  should  be  added 
and  the  mixture  left  in 
a  conical  glass  till  the 
elastic  fibres  settle  to 
the  bottom.  Thus 
they  may  be  isolated, 
and  in  well  marked 
cases  exhibit  the  alve- 
olar arrangement  of 
the  lung  tissue.  Too 
prolonged  an  expo- 
sure to  the  caustic 
will  lead  to  the  solu- 
tion of  the  elastic 
fibres  as  well  as  of 
the  other  constituents 
(Fig.  72). 

III.  Fibrin 
caists,  often  large 
enough  to  attract  the 
unaided  eye,  are  still 


Fig.  73. — Bioncliial  cast  from  a  case  of 
■plastic  bronchitis.      Natural  size. 


The  Sputum. 


261 


more  frequently  visible    under  a  low  power   of  the 
microscope  (Fig.  73). 

IV.   Ciirsclmiaiiii's  spirals  are  found  in  the 
sputum  of  asthmatic  patients.     Some  of  the  sputum 


'm^^- 


Fig.  74.— Cursehmaun's  spirals  in  sputum,     x  200  and  natural  size. 

should  be  spread  out  on  a  piece  of  glass  on  a  black 

sui-face.       The    spirals    look    like    little    sago    grains. 

When    unrolled,    they 

appear    as     convoluted 

threads  which  may  be 

quite  an  inch  in  length.      ,,  .^5^^,^ 

IJnder  the    microscope     ■;  ;P  ^ 

they     show     a    central    •;;.-.. 

core,    round    which    a  K:^^^^^'- 

sheath  of  tough  mucus, 

with  a  large  number  of    ',---^  ^^ 

small     round     cellular 

elements  in  it,  is  coiled 

(Fig.   74).  Fig.  75.— Charcot-Leyden  crystals.    x350. 

V.   Crystals.— (1) 
In   asthma,   fine    colourless   crystals    wdth   sharp    ex- 
tremities are  often  found.      They  are  often  associated 


262 


ReSPIRA  tor  Y   SyS  7  EM. 


Fig.  76. — Ova  of  Distoma  pulmonale  in  sputum.     High  power. 


Fig.  77  —Actinomyces  in  sputum. 


The  Sputum. 


263 


with  the  spirals  already  described,  and  are  known  as 
Cliarcot  -  Leydeii   crystals.     They  are  probably 

phospliates  of  an  organic  base  (Fig.  75). 

(2)  Fatty  acid  crystals  are  needle-shaped,  and 
generally  occur  in  clusters. 

(3)  C'liolesteriii  occurs  in  rhomboidal  plates, 
which  generally  have  a  small  notch  in  one  corner. 
They  occur  in  old  purulent  sputum  from  pulmonary 
cavities,  but  their  presence  is  uncommon. 

(4)  Hppiiiatoidiii  crystals  occur  where  there 
has  been  an  old  hpemorrhage  in  cases  of  abscess  and 
empyema.  They  have  a  characteristic  brown-yellow 
colour,  and  appear  as  needles,  rhombi,  and  plates. 

(5)  L.eiiciii  and  tyrosiii  may  be  found  on  rare 
occasions  in  pus  from  old  perforated  empyemata. 

VI.  Parasites.  —  These  belong  both  to  the 
animal  and  vegetable  kingdoms.  Of  animal  parasites, 
ecliinococci  are  the  most  important.  The  presence 
of  booklets,  and  still  oftener 
of  fragments  of  the  lam- 
inated  ectocyst,  are  the 
usual  indications  of  their 
existence  (see  p.  93).  In 
China  and  other  parts  of 
Eastern  Asia  Distoma 
pulmonale  is  frequently 
found.  Its  presence  causes 
sharp  attacks  of  haemo- 
ptysis, which  may  be  mis- 
taken for  the  haemoptysis 
of  phthisis.  Microscopic 
scrutiny  of  the  sputum,  however,  generally  reveals 
characteristic  ova   (Fig.   76). 

The  vegetable  parasites  are  fairly  numerous.  Be- 
sides bacteria,  which  are  considered  in  a  separate 
chapter,  and  amongst  which  the  most  important  are 
tubercle  bacilli,  pneumococci,  and  Pfeiffer's  bacillus, 


Fig.  7S.  -  Aspei'gillus  fumigatus. 


264  Respiratory  System. 

some  of  the  higher  fungi  are  also  found,  the  most 
important  being  actinomyces  and  aspergilliis 
fiuiiigatus  (Figs.  77,  78). 


APPENDIX    TO    CHAPTER    VI. 

On  Graphic  Methods  of  Eecordixg  the  Coxditions 
Observed  in  the  Heart  and  Lungs. 

1.  Full-size  outlines  of  the  heart. 

The  position  of  the  nipples,  and  the  outlines  of  the  clavicles, 
ribs,  and  sternum,  should  be  carefully  traced  on  the  chest  -with 
a  dermatograph  pencil,  and  the  same  should  be  done  for  the 
outlines  of  relative  and  absolute  dulness  of  the  heart  and  liver. 
These  tracings  should  then  be  gone  over  rapidly  with  a  small 
paint  brush  dijDped  in  sweet  almond  oil,  and  a  sheet  of  tissue 
paper  pressed  down  upon  the  patient's  chest.  The  oil  will 
leave  a  mark  on  the  paper,  which  can  be  more  strongly  traced 
by  a  pencil  after  the  paper  has  been  removed. 

An  alternative  method  is  to  photograph  the  chest 
wdth  the  lines  drawn  in.  This  has  the  convenience  of  pre- 
serving the  record  in  a  less  bulky  form.  A  scale  of  inches 
should  in  this  case  be  laid  across  the  patient's  epigastrium 
to  permit  of  absolute  measurements  being  taken  from  the 
photograph. 

2.  The  use  of  symbols  on  outline  charts. 
(«)  The  heart. — The  presence  and  position  of  murmurs 

are  easily  indicated  by  shading.  Their  intensity  is  roughly 
represented  by  the  heaviness  of  the  shading.  Examples  of 
this  method  are  seen  ia  Figs.  34,  35,  and  39.  When  two  syn- 
chronous murmurs  are  present,  and  one  wishes  to  show  where 
the  first,  after  becoming  fainter,  gives  place  to  the  second,  which 
grows  increasingl)'-  loud  as  the  stethoscope  is  carried  along  the 
line  joining  their  areas  of  maximum  intensity,  one  makes  use 
of  the  musical  signs  of  diminuendo  and  crescendo,  ^  and  ^. 
The  situation  of  pericardial  friction  is  indicated  bj'  a  zigzag 
line,  wv%w^.  When  the  apex  beat  does  not  reach  the  edge 
of  the  deep  cardiac  dulness,  its  situation  is  shown  by  a  small 
cross.  X . 

(h)  The  lung's. — The  position  of  any  dull  area  is  in- 
dicated by  shading.  If,  following  the  suggestion  of  Prof. 
Sahli,  one  represents  superficial  dulness  in  blue  chalk  and 
deep  in  red,  one  can  not  only  make  the  record  clearer,  but  can 


Graphic  Records  of  Physical  Signs.         265 

also  superpose  on  the  same  chart  auscultatory  phenomena  in 
black  symbols  without  clogging  it.  The  auscultatory  phe- 
nomena are  well  represented  by  the  following  symbols.* 


1.  Types  of  breathing  : — • 
[a)  Vesicular. 

A      A     A 

Puerile.        Normal        Feeble. 
Ailult. 


o 

None. 


/\ 


Inter- 
rupted. 


A 


Harsh,  with 
expiration 
prolonged. 


[b]  Transition  \  "  Bronchovesicular  " 
Type.  \     or  indeterminate, 


{c)  Bronchial. 


{(l)  Amphoric. 


//\ 


Tubular 

or 

High-pitched. 


Medium- 
pitched. 


Low- 
pitched. 


00 

High- 
pitched. 


C?0         O^ 


Medium- 
pitched. 


Low- 
pitched. 


2.  Accompaniments : — 
(a)  Friction.  AAAA       AVWW     AnAw^v/ 


/  TO 

Fine.  Medium. 


c 
Coarse. 


(b)  Dry  rales. 

(c)  Moist  rales  : — 
Consonating. 

Non-consonating. 


/// 


Sibilant 
rhonchi. 


/// 

Medium- 
pitched 
rhonchi. 


Fine. 


Medium. 


/// 

Sonorous 
rhonchi. 


o  o 

Coarse. 


If  the  accompaniments  occur  during  inspiration,  the  letter 
i  is  prefixed  to  the  symbol ;  if  during  expiration,  e. 


*  Mostly  after  Dr.  Wyllie. 


266 


R  ESP  IRA  TOR  Y  SVS  TRM, 


Vocal  resonance  is  indicated  by  the  letters  V.R.,  followed 
t»y  +  1,  +  2,  +  3,  if  it  is  slightly,  moderatel)',  or  greatly  in- 
creased; or  —  1,  —  2,  —  3,  if  it  is  proportionately  diminished. 


Fig.  79. — Record  of  pneumonia. 


Other  physical  signs  are  best  indicated  by  various  letters  of 
the  alphabet.  The  accompanying  figure  (Fig,  79)  illustrates 
the  application  of  these  symbols  to  a  case  of  pneumonia. 


267 


CHAPTER  VII. 
The  Urine. 

The  nietliod  of  interrogating  a  patient  whose 
symptoms  point  to  an  affection  of  the  urinary 
system  has  ah^eacly  been  described  (p.  9),  and  the 
physical  examination  of  the  kidneys  has  been  con- 
sidered along  with  that  of  the  other  abdominal 
organs  (p.  72). 

In  this  chapter  we  propose  to  take  up  the  examin- 
ation of  the  renal  secretion. 

Collection  of  Samples. 

Owing  to  the  variations  in  the  composition  of  the 
urine  at  different  times  of  the  day,  the  sample  examined 
should,  if  possible,  be  taken  from  the  total  urine  of  the 
twenty-four  hours.  If  only  one  sample  can  be 
obtained  it  should  be  that  which  is  passed  about 
three  hours  after  taking  a  meal,  as  abnormal  ingre- 
dients are  then  more  likely  to  be  present.  The  sample 
should  be  poured  into  a  tall  conical  glass,  covered, 
and  allowed  to  stand  for  some  hours  in  a  cool  place. 

Any  suspended  matters  soon  settle  to  the  bottom 
of  the  glass,  and  the  examination  of  the  sample  may 
then  be  proceeded  with.  This  should  be  conducted 
(1)  physically,  (2)  chemically,  (3)  microscopically. 

SECTION  L— PHYSICAL  EXAMINATION  OF 
THE  URINE. 

Attention  should  be  paid  to  the  following  points  : 
(rt)  Quantity,  (6)  colour,  (c)  consistence,  {d)  odour, 
(e)  density,  (/)  naked-eye  characters  of  the  deposit. 

1.  Quantity.       The     amount    of    urine   passed 


268  The   Urine. 

during  the  day  should  be  measured  separately  from 
that  passed  during  the  night.  The  sum  of  the  two  gives 
the  total  for  twenty-four  hours.  The  bladder  should 
be  emptied  at  a  fixed  hour — say  8.30  a.m.,  and  the 
product  discarded.  All  the  urine  passed  during  the 
day  is  carefully  collected,  and  the  bladder  emptied 
again  at  8.30  p.m.,  the  product  being  added  to  the 
day's  secretion.  This  is  the  amount  of  the  '■'■day  urine.'''' 
The  bladder  is  again  emptied  at  8.30  next 
morning,  and  the  product  added  to  that  which  has 
been  passed  during  the  night.  The  total  quantity 
is  the  "  night  firiiie."  This  added  to  the  day  urine 
gives  the  total  for  twenty-four  hours. 

It  is  often  difficult  to  collect  all  the  urine  that  is 
passed,  some  being  lost  with  the  motions.  This  is 
especially  the  case  with  children,  female  patients,  and 
those  who  pass  their  evacuations  involuntarily. 
Where  great  accuracy  is  required,  recourse  must  be 
had  to  the  catheter. 

A  healthy  adult  male  passes  on  an  average  50  ozs. 
(1450  cc.)  of  urine  in  twenty-four  hours  ;  women  a 
few  ounces  less. 

The  existing  tables  which  represent  the  amount 
of   urine    secreted   by   children    are    by    no    means 
trustworthy,  the  quantities  being  probably  too  high. 
The  following  may  be  taken  as  representing  approxi- 
mately the  average  secretion   at   various  ages.      It  is 
constructed   from  data  furnished  to  us  by  Dr.  Still  as 
the   result   of   his  observations  at  the  Hospital   for 
Sick  Children,  London. 
Below  two  years  of  age 
Between  two  and  three  years  . . . 
„  three  and  four      ., 

„         four  and  five        ,, 
At  six  years 
,,    eight  years  ... 
„    twelve    ,,     ... 


4- 

-6  ozs. 

daily. 

6- 

-8 

8- 

-9        , 

9- 

-10 

12 

16 

20 

Quantity.  269 

Above  this  the  quantity  gradually  approximates  to 
the  adult  standard.  The  most  noteworthy  point 
about  these  figures  is  the  comparative  smallness  of 
the  amount  of  urine  secreted  by  children.  One 
may  say  roughly  that  between  the  ages  of  two  and 
twelve  the  number  of  ounces  of  urine  passed  per 
day  is  equal  to  twice  the  age  of  the  child  in  years. 

Normally,  very  much  more  urine  is  secreted 
during  the  day  than  during  the  night.  The  normal 
proportion  of  day  urine  to  night  urine  is 
::  100  :  25-60.  Approximation  of  the  night  quantity 
to  that  of  the  day  is  always  abnormal,  and  is  especi- 
ally apt  to  occur  in  chronic  renal  disease,  of  which, 
indeed,  it  may  constitute  one  of  the  earliest  signs. 
Thus  the  proportion  of  day  to  night  urine  may 
become  ::  100: 100  or  even  200.  The  solids  are 
increased  in  proportion  to  the  water. 

An  increased  secretion  of  urine  occurs  physiologi- 
cally after  increased  consumption  of  food  or  drink, 
and  after  exposure  to  cold.  Conversely,  one  finds  the 
secretion  diminished  when  little  food  or  drink  has 
been  taken,  and  after  exposure  to  heat — especially  if 
followed  by  sweating. 

A  i^atkological  increase  in  the  urine  occurs  in 
diseases  associated  with  an  increased  arterial  pressure 
— e.g.  granular  kidneys — also  in  both  forms  of  diabetes, 
during  the  absorption  of  exudates  and  in  some 
neurotic  conditions — e.g.  hysteria.  Abnormal  diminu- 
tion of  urine  is  found  where  the  arterial  pressure  is 
lowered  or  the  intravenous  pressure  in  the  kidney 
increased — e.g.  in  advanced  mitral  disease;  also  in 
all  fevers  and  in  cerebral  irritation — e.g.  concussion. 
(&)  Colour  of  the  urine. 

Normal  urine  is  said  to  have  the  colour  of  amber 
or  pale  sherry.  The  exact  tint  fluctuates  widely 
even  in  health,  depending  upon  the  degree  of  dilution 
and    upon    the    reaction.     An    acid  urine  is  always 


270 


The  Urine. 


darker  than  one  which  is  alkahne,  even  when  they 
are  equally  concentrated.  The  nature  of  the  pigment 
to  which  normal  urine  owes  its  colour  is  not  fully 
understood.  It  is  not  urobilin,  that  pigment  only 
occurring  in  very  small  quantity  in  the  urine  under 
normal  conditions.  In  febrile  and  some  other 
diseases,  however,  a  large  quantity  of  urobilin  may 
appear  in  the  urine.  The  latter  has  then  a  warm 
orange  colour,  and  usually  shows  a  dull  pink  tint  at 
the  apex  of  a  conical  glass. 

If  examined  spectroscopically  in  a  thin  layer  the 
urobilin  band  will  be  seen  in  the  green  between 
h  and  F  (Fig.  80).     Such  a  urine  is  often  dichroic — 


E  h 


GREEN 

Fig.  80. 

1,  Spectrara  of  Urobilin. 

2,  Spectrmn  of  Urobilin  masked  by 

other  pigments. 

looking  red  by  transmitted  and  green  by  reflected 
light.  The  presence  of  excess  of  urobilin  may  be  con- 
firmed by  rendering  the  urine  strongly  alkaline  with 
ammonia,  filtering,  and  adding  to  the  filtrate  a  few 
drops  of  a  10  per  cent,  solution  of  chloride  of  zinc. 
If  excess  of  urobilin  is  present,  the  solution  becomes 
fluorescent. 

The  following  are  the  chief  varieties  of  alteration 
in  colour  of  the  urine,  with  their  causes  : — 


Colour.  271 

Pallor. — This  is  present  whenever  a  large  excess  of 
urine  is  being  secreted.  It  may  also  occur  from  an 
absolute  diminution  in  the  amount  of  urinary- 
pigment.  This  is  the  case  in  diabetes ;  a  diabetic 
urine  is  pale  even  when  concentrated. 

Orange-coloured  or  reddish  brown.  —  After  the 
administration  of  rhubarb,  senna  and  chrysophanic 
acid.  Distinguished  from  blood  by  the  fact  that 
addition  of  a  mineral  acid  causes  the  urine  to 
become  yellow,  while  an  alkali  turns  it  dark  red. 
Some  bilious  urines  are  also  of  an  orange  tint  (p.  31 9). 

Dark  hrown. — This  may  be  due  to  methsemo- 
globin,  which  is  found  in  haemorrhage  into  the 
kidneys,  and  in  paroxysmal  hsemoglobinuria.  The 
spectroscope  shows  a  band  in  the  red  in  addition  to 
two  bands  very  near  those  of  oxyhaemoglobin  (p.  207). 
Red. — From  blood  (see  p.  304). 
Port  wine  coloured. — Due  to  the  presence  of 
hsematoporphyrin  (see  p.  306). 

Broivnish  black. — This  maybe  due  to  the  presence 
of  melanin,  which  is  sometimes  excreted  in  the  urine 
in  cases  of  extensive  melanotic  sarcoma  wherever 
situated.  Such  a  urine  usually  darkens  on  standing, 
and  may  even  become  quite  black.  It  does  not 
reduce  cupric  oxide  in  alkaline  solution.  On 
addition  of  ferric  chloride  the  urine  yields  a 
brownish  turbidity,  or  even  a  black  precipitate  which 
is  soluble  in  excess. 

Greenish  black. — From  the  presence  of  aromatic 
compounds  (hydroquinone,  etc.)  after  the  administra- 
tion of  carbolic  acid,  guaiacol,  salol,  resorcin,  naphtha- 
line, etc. 

Greenish  or  yellowish  green. — From  the  presence 
of  bile  (see  p.  319).  The  adminivstration  of  santonin 
is  also  followed  by  a  yellowish  green  colour,  but  on 
adding  an  alkali  the  urine  becomes  dark  red. 

Yellowish  and  milky. — From  the  presence  of  pus 


272  The  Urine. 

(see  p.  322)  or  of  fat.  The  fat  may  form  an 
emulsion  as  in  chyluria,  or  it  may  be  present  in  the 
form  of  droplets  which  float  on  the  surface  of  the 
urine  (lipuria);  the  latter  condition  sometimes  occurs 
in  advanced  fatty  disease  of  the  kidney.  The 
presence  of  fat  in  the  urine  can  always  be  shown  by 
the  addition  of  a  little  caustic  soda  and  ether.  On 
shaking  up  the  mixture  the  fat  is  dissolved  out,  and 
is  left  behind  on  evaporation  of  the  ether. 

Bluish  or  greenish  blue. — This  occurs  when  the 
urine  contains  a  large  excess  of  indigo- forming 
substances — e.g.  in  some  cases  of  typhus.  It  is 
especially  seen  after  putrefaction  has  occurred. 

The  urine  may  be  opalescent  from  the  presence 
of  various  substances  in  suspension.  If  the 
opalescence  persists  after  filtration,  it  is  due  to  the 
presence  of   bacteria. 

A  slight  opalescence  which  causes  the  urine  to 
look  smoky  is  produced  by  the  presence  of  small 
quantities  of  blood  (see  p.  304). 

Alcaptonuria. — This  is  a  condition  in  which 
the  urine  is  natural-looking  when  passed,  but  when 
exposed  to  the  air  it  becomes  gradually  darker  from 
the  surface  downwards  ;  ultimately  it  may  be  dark 
brown  or  black.  It  is  due  to  the  presence  in  the 
urine  of  dioxyphenyl  acetic  acid. 

It  may  occur  spontaneously  in  quite  healthy 
persons.  The  addition  of  an  alkali  causes  the  urine 
to  become  dark  at  once.  Such  urines  reduce  alkaline 
solution  of  cupric  oxide.  Urines  containing  melanin 
also  become  darker  on  exposure  to  the  air  owing  to 
oxidation  of  the  pigment,  but  they  do  not  reduce 
cupric  oxide. 

Carbolic  acid  urine  also  becomes  darker  on 
exposure  to  air  owing  to  the  oxidation  of  the  hydro- 
quinone  which  it  contains  into  pigments  not  yet 
fully  investigated. 


CONSJSTEXCE    AND    OdOUR.  273 

In   alkcaline    urines    an     iriclesceiit     pellicle 

frequently  appears  on  the  surface.  When  the  urine 
has  cooled  this  can  be  skimmed  off  like  a  thin  brittle 
film.  It  is  composed  of  phosphate  of  lime.  The  idea 
formerly  entertained  that  such  a  pellicle  occurs 
especially  in  the  urine  of  pregnancy  is  groundless. 

(c)  Consistence  of  urine. — In  health  the  urine 
is  quite  watery  in  consistence.  If  much  sugar  or 
bile  is  present  it  is  less  mobile,  and  in  the  presence 
of  bile  or  of  much  albumin  the  froth  which  forms 
on  shaking  is  more  persistent  than  is  usual.  Alkaline 
urine  containing  pus  may  be  quite  ropy.  A  special 
alteration  in  consistence  occurs  in  the  condition 
known  as  Fibrinuria.  When  this  is  present  the  urine 
is  reddish  yellow  when  passed,  but  soon  sets  into  a 
jelly  which  contracts  somewhat  on  standing.  If  only 
little  fibrin  is  present  the  whole  urine  may  not 
coagulate,  but  a  sticky  sediment  forms  at  the  bottom 
of  the  vessel.  Fibrinuria  is  due  to  the  entrance  of 
blood  plasma  into  the  urinary  tract.  It  occurs  as  a 
very  rare  symptom  of  villous  growth  in  the  bladder, 
and  sometimes  also  after  the  administration  of 
cantharides.  The  fibrin  may  be  recognised  as  such 
by  washing  it  and  then  placing  in  1  per  cent.  HCl. 
It  swells  up,  but  is  not  dissolved  unless  pepsin  be 
also  added. 

{d)  Odour. — N^ormal  urine  has  a  characteristic 
"  aromatic "  odour.  When  the  urine  has  stood  for 
some  time  the  odour  becomes  ammoniacal.  In  cases 
where  there  is  an  abnormal  communication  between 
some  part  of  the  urinary  tract  and  the  intestine  the 
odour  may  become  f  secal.  In  acetonuria  the  odour  is 
fruity.  After  the  administration  of  turpentine  the 
urine  has  an  odour  like  violets.  Cubebs,  santonin, 
and  some  other  drugs  also  impart  to  it  their  peculiar 
smells.  In  diabetes  the  odour  has  been  compared 
to  that  of  new-mown  hay. 
s 


274  The  Urine. 

{e)  Density. — Clinically  the  specific  gravity  of 
urine  is  always  taken  with  the  instrument  known  as  a 
iiriiionieter.  An  ordinary  urinometer  is  graduated 
for  a  temperature  of  15°  C,  and  will  record  variations 
in  specific  gravity  from  1000  up  to  1060. 

How  to  use  the  urinometer.— The  urine  should 
be  allowed  to  cool,  and  sliould  be  placed  in  a  tall 
jar,  wide  enough  to  allow  the  urinometer  to  float 
freely  without  touching  the  sides.  All  bubbles 
must  be  removed  ,from  the  surface  by  means  of 
bibulous  paper.  The  urinometer  should  be  wiped 
clean  and  placed  floating  in  the  centre  of  the  jar. 
The  eye  is  then  placed  level  with  the  surface  of  the 
urine  and  the  division  of  the  scale  to  which  the  latter 
reaches  read  off".  Care  must  be  taken  to  read  the 
level  of  the  true  surface  of  the  urine,  not  the  edge  of 
the  rim  which  heaps  itself  up  around  the  shaft  of  the 
urinometer. 

If  only  a  small  specimen  of  the  urine  is  obtainable 
it  may  be  necessary  either  to  use  "specific  gravity 
beads,"  or  else  to  add  water  to  it  in  order  to  get 
enough  fluid  to  float  the  urinometer.  The  specific 
gravity  found  is  then  multiplied  by  the  necessary 
figure  according  to  the  degree  of  dilution. 

Normal  urine  has  a  specific  gravity  varying  from 
1015  to  1025.  In  children  it  is  usually  somewhat 
higher  than  in  adults.  If  very  concentrated  the 
specific  gravity  may  rise  to  1035  even  in  health. 

In  normal  urine  the  specific  gravity  is  in  direct 
proportion  to  the  amount  of  urea  present.  An 
abundant  urine  of  loiv  specific  gravity  is  suggestive 
either  of  diabetes  insipidus,  or  of  chronic  renal 
disease.  An  abundant  urine  of  high  specific  gravity 
is  characteristic  of  diabetes  mellitus.  In  the 
latter  condition  the  specific  gravity  may  reach  1075  ; 
in  most  cases,  however,  it  is  between  1040  and 
1045.     In  diabetes  insipidus,  on  the  other  hand,  the 


Characters  of  Deposit.  275 

specific  gravity  may  fall  to  nearly  that  of  distilled 
water. 

The  presence  of  albumin  in  the  urine  does,  not 
materially  affect  its  specific  gravity.  It  should  also 
be  borne  in  mind  that  the  urinometer  is  entirely 
unaffected  by  the  presence  of  merely  suspended 
substances. 

Esfiiiiatioii  of  tlic  aiiioiiiit  of  solids.— 
This  may  be  roughly  done  by  multiplying  the  last  two 
fi^gures  of  the  specific  gravity  by  2*33.  The  result  is 
the  number  of  grammes  of  solids  in  1  litre  of  the 
urine,  or  the  number  of  grains  of  solids  in  1,000  fluid 
grains  of  urine  ;  e.g.  if  the  specific  gravity  of  a  urine 
is  1020,  it  contains  20  x  2*33  =  46-6  grammes  of 
solids  in  every  litre,  or  4-6  percent.  This  multiplied 
by  4*375  gives  grains  per  ounce — in  this  case  20*1. 
The  average  daily  output  of  solids  in  the  urine  is 
about  60-70  grammes  (2-2|  oz.).  The  above  mode  of 
calculation  is  not  applicable  to  urine  containing 
abnormal  ingredients,  e.g.  sugar  or  albumin. 

(/)  ]\al£ed-eye  characters  of  the  deposit. 
— When  normal  urine  has  stood  for  some  time  there 
appears  in  it  a  deposit  of  "  iniiciis."  This  forms  a 
woolly -looking  cloud  which  usually  settles  to  the 
bottom  of  the  glass,  but,  if  the  urine  be  of  high 
specific  gravity,  may  be  in  the  middle  of  the  glass  or 
even  at  the  top.  It  should  be  mentioned  that  this 
substance  probably  does  not  consist  of  true  mucin. 
It  has  been  described  as  a  nucleo-albumin.  This, 
however,  is  by  no  means  certain,  as  the  body  has 
not  been  investigated  with  regard  to  the  presence  or 
absence  of  the  different  essential  characters  of  the 
nucleo-albumin  group. 

If  traces  of  blood  are  present  in  the  urine  the 
cloud  of  "  mucus  "  has  often  a  brownish  tint. 

The  normal  urinary  ingredients  which  may  sepa- 
rate  out  in   the   form  of   a  deposit,    visible  to  the 


276  The   Urine. 

naked  eye,  are — earthy  phosphates,  urates  and  free 
uric  acid. 

Phosphates. — The  phosphates  of  calcium  and 
magnesium  separate  out  if  the  urine  is  neutral  or 
alkaline.  They  form  a  colourless  deposit.  It  can  be 
recognised  by  the  fact  that  if  a  little  of  it  be  trans- 
ferred by  a  pipette  to  a  test  tube,  and  some  dilute 
acetic  acid  added,  the  deposit  dissolves.  A  deposit 
of  pus  is  apt  to  be  mistaken  for  one  of  phosphates. 
They  may  be  distinguished  b}^  moving  the  glass  gently 
from  side  to  side.  It  will  then  be  found  that  a  deposit 
of  phosphates  is  more  flocculent  and  less  compact  than 
one  of  pus,  and  the  surface  layers  of  it  are  easily 
detached  on  shaking,  and  float  up ;  this  does  not 
happen  in  the  case  of  pus.  Acetic  acid  also  does  not 
dissolve  pus,  while  the  addition  of  caustic  alkali 
renders  it  ropy.  If  the  urine  be  acid,  however,  and 
its  reaction  has  not  been  tested,  a  deposit  of  pus  cannot 
be  distinguished  with  the  naked  eye  from  a  deposit  of 
phosphates.  It  should  also  be  borne  in  mind  that 
deposits  of  phosphates  and  pus  often  occur  together. 

Urates. — The  quadri-urates  of  sodium,  potassium, 
and  ammonium  may  form  a  deposit  if  the  urine  be 
concentrated  or  highly  acid.  They  may  appear,  even 
in  health,  when  the  urine  cools.  Owing  to  their 
ajQBlnity  for  the  urinary  pigments  the  deposit  is  usually 
coloured,  being  commonly  red,  or  like  terra-cotta,  form- 
ing what  is  known  as  the  "torick- dust"  deposit. 
If  the  urinary  pigment  be  scanty,  however,  the 
deposit  may  be  merely  yellowish,  or  even  colourless. 
Deposits  of  quadri-urates  can  alw^ays  be  recognised  by 
the  fact  that  they  disappear  rapidly  on  heating  the 
urine.  The  heating  ought  to  be  accomplished  gradually, 
because  the  urine  might  also  contain  albumin,  which, 
if  the  urine  were  rapidly  heated,  might  be  coagulated 
before  the  deposit  of  urates  had  all  had  time  to  clear 
up,  and  thus  confusion  might  arise.     Acetic  acid  does 


Characters  of  Deposit.  277 

not  dissolve  a  deposit  of  urates.  On  the  other  hand 
strong  mineral  acids,  such  as  nitric  acid,  dissolve  the 
deposit  at  once  with  the  production  of  effervescence. 

Acid  urate  of  soda,  is  a  rare  deposit.  It 
occurs  in  acid  urines.  It  forms  a  yellowish,  granular, 
sandy-looking  sediment.  It  does  not  dissolve  readily 
on  heating. 

Acid  iii'ate  of  auiiiioitia  forms  a  very  similar 
deposit,  but  it  occurs  in  ammoniacal  urines,  and  is 
therefore  mixed  up  with  a  deposit  of  phosphates. 

Uric  acid. — This  may  form  a  scanty  deposit 
visible  to  the  naked  eye.  The  deposit  occurs  in  the 
form  of  crystalline  grains  of  a  darkish  brown  colour, 
and  is  therefore  known  as  the  "  cayeime-pepper 
deposit."     When  in  doubt  use  the  microscope. 

The  sulphates  practically  never  form  urinary 
deposits.  Oxalates  do,  but  the  deposit  is  always 
scanty,  mixed  up  with  the  cloud  of  mucus,  and  not 
easy  to  recognise  with  the  naked  eye.  We  have 
already  spoken  of  the  occurrence  of  fibrin,  and  the 
other  abnormal  ingredients  which  may  be  deposited 
will  be  described  in  the  section  on  the  microscopical 
examination  of  the  urine. 

We  would  warn  the  reader  against  the  common 
mistake  of  supposing  that  a  substance  is  necessarily 
being  excreted  in  excess  when  it  appears  in  the  urine 
in  the  form  of  a  deposit.  This,  of  course,  is  not 
necessarily  the  case  at  all.  Thus  the  occurrence  of  a 
"  cayenne-pepper  "  deposit  does  not  necessarily  mean 
that  the  patient  is  excreting  an  excess  of  uric  acid. 
It  may  merely  be  due  to  the  fact  that  the  conditions 
which  normally  cause  the  uric  acid  to  be  in  solution 
have  become  modified.  The  urine  may  be  abnormally 
acid,  for  example,  or  it  may  be  deficient  in  colouring 
matter  or  in  salts,  all  of  which  conditions  tend  to 
lessen  the  solubility  of  uric  acid,  and  to  favour  its 
deposition  in  the  form  of  crystals.     Similarly  in  the 


278  The   Urine. 

case  of  a  deposit  of  phosphates.  That  does  not  mean 
that  more  phosphoric  acid  is  being  ehminated,  it 
merely  indicates  that  the  urine  has  become  alkaline. 

SECTION  II.— CHEMICAL   EXAMINATION 
OF  THE  URINE. 

1.  Reaction. — This  is  taken  with  litmus  paper. 
The  urine  is  usually  acid  in  reaction.  This  is  not 
due  to  the  presence  of  free  acid,  but  to  acid  salts — 
chiefly  the  acid  phosphate  of  sodium  (NaHoPO^). 
Sometimes  the  reaction  is  blue  to  red  litmus  paper, 
and  red  to  blue  litmus  paper.  This  amphoteric  re- 
action is  due  to  the  presence  of  large  quantities  of 
the  disodic  phosphate  (NaoHPO^)  in  addition  to  the 
acid  salt.  It  has  no  clinical  significance.  The  urine 
may  be  normally  alkaline  after  meals.  This  is  some- 
times known  as  the  "  alkaline  tide^  It  reaches  its 
acme  three  hours  after  the  taking  of  a  meal.  It 
is  chiefly  due  to  the  disodic  phosphate  replacing  the 
acid  salt.  Alkalinity  of  the  urine  may  be  due  to 
ammonia.  This  can  be  detected  by  its  smell,  also  by 
the  fact  that  if  the  red  litmus  paper  which  has 
been  turned  blue  be  heated,  the  red  colour  is  restored, 
owing  to  the  ammonia  being  driven  off. 

The  degree  of  acidity  of  the  urine  cannot  be 
measured  by  direct  titration  with  a  standard  alkaline 
solution  in  the  usual  way,  for  the  reason  that  none  of 
the  phosphates  of  sodium  react  neutral  to  tlie  usual 
indicators.  To  those  who  might  wish  to  make  tJie 
estimation  the  method  of  Haussmann^  may  be  recom- 
mended, but  it  is  too  complicated  for  general  use.  In 
any  case  the  exact  quantitative  estimation  of  the 
acidity  of  the  urine  is  of  no  clinical  service.  For 
ordinary  purposes,  the  intensity  of  the  red  colour 
produced  in  litmus  paper  is  a  sufficient  indication 
of  the  degree  of  acidity. 
*  "  Verhand.  d,  14ten  Cong.  f.  inn.  Med."    Wiesbaden,  1896. 


Chlorides.  279 

2.  Exaiiiiiiatioii  of  the  urine  for  its  nor- 
mal  non-nitrog^enous  constituents. 

(1)  Chlorides. — Chloride  of  sodium  is  the  chief 
inorganic  constituent  of  normal  urine.  Small  quanti- 
ties of  the  potassium  salt  also  occur. 

Qualitative  test  for  their  preseiice. — Filter  the 
urine  if  not  already  clear.  If  albumin  is  present 
remove  it  by  boiling.  Add  to  ^  an  inch  of  the  urine 
in  a  test  tube  a  few  drops  of  nitric  acid  (be  sure  that 
the  acid  used  is  quite  pure  and  free  from  HCl),  and 
then  as  much  of  a  3  per  cent,  solution  of  nitrate 
of  silver  as  there  is  of  urine.  If  the  normal  amount 
of  chlorides  is  present  an  abundant  curdy  jDrecipitate 
appears  at  once.  If  the  chlorides  are  diminished,  the 
solution  merely  becomes  milky.  If  a  mere  trace  of 
them  is  present,  the  solution  is  opalescent,  and  if  they 
are  altogether  absent  it  remains  quite  clear. 

The  use  of  the  nitric  acid  is  to  prevent  the  precipi- 
tation of  phosphate  of  silver. 

Quantitative  estimation. — For  ordinary  clinical  use 
]?Iohr's  method  is  to  be  recommended.  One  pro- 
ceeds as  follows  : — 

Place  10  cc.  of  the  urine,  freed  if  necessary  from 
albumin,  in  a  beaker,  and  mixed  with  50  cc.  of 
distilled  water.  Add  three  drops  of  a  solution  of 
neutral  chromate  of  jDotassium  (1  in  20)  and  a  pinch 
of  calcium  carbonate.  The  use  of  the  latter  is  to 
neutralise  any  free  acid  that  may  be  present.  Fill  a 
burette  with  standard  solution  of  nitrate  of  silver 
(Appendix,  9).  Run  the  silver  solution  into  the 
beaker,  stirring  all  the  time.  A  precipitate  of  chloride 
of  silver  falls  out.  Whenever  the  least  trace  of  a 
pink  colour  appears  stop.  This  can  be  best  appre- 
ciated by  allowing  the  precipitate  to  settle,  which  it 
very  quickly  does.  If  the  sediment  is  in  the  least 
flesh-coloured,  enough  silver  solution  has  been  added. 
The  appearance  of  the  pink  colour  indicates  that  the 


2  8o  The   Urine. 

silver  has  united  with  all  the  chlorides  present  and 
has  begun  to  form  chromate  of  silver  with  the  potas- 
sium chromate. 

Calculation. — Onecc.  should  be  deducted  from  the 
total  number  of  cc.  of  silver  nitrate  used.  The  reason 
for  this  is  that  there  exists  in  urine,  besides  chlorides, 
other  substances  with  which  the  silver  unites  more 
readily  than  it  does  with  the  chromate.  Roughly, 
the  deduction  of  1  cc.  is  sufficient  to  allow  for  these. 
Every  remaining  cc.  of  the  solution  used  is  equivalent 
to  10  milligrammes  of  sodium  chloride.  Suppose 
11  cc.  to  have  been  used  in  all,  deducting  1  cc.  there 
is  left  10  cc.  This  is  equivalent  to  100  mg.  sodium 
chloride,  which  will  be  the  quantity  of  chlorides  in 
the  amount  (10  cc.)  of  urine  used.  If  1,500  cc.  was 
the  amount  of  urine,  in  twenty-four  hours  it  will 
contain  15  grammes  of  sodium  chloride. 

For  the  accurate  estimation  of  small  quantities  of 
chlorides  in  the  urine  the  method  of  Volhai'd  should 
be  employed,  but  for  a  description  of  it  special  works 
must  be  consulted. 

About  12  grammes  represents  the  average  daily 
excretion  of  chlorides  in  health.  The  chief  cause 
of  physiological  variation  is  the  nature  of  the  diet. 
Pathologically,  chlorides  are  found  to  be  diminished 
in  all  febrile  affections  with  the  exception  of  malaria. 
In  the  latter  disease  the  chlorides  are  increased  during 
the  febrile  period,  diminished  in  the  apyrexial  in- 
tervals. In  acute  croupous  pneumonia,  the  chlorides 
are  more  markedly  diminished  than  in  any  other 
fever.  They  may  indeed  disappear  entirely.  We 
reojard  their  behaviour  as  of  great  diac^nostic  value. 
In  no  other  disease,  except,  perhaps,  typhus  and  rheu- 
matic fevers,  does  such  a  notable  diminution  occur.  In 
the  diagnosis  of  pneumonia  from  empyema  and  pleurisy 
the  test  is  of  special  help.  The  chlorides  are  increased 
after  the  crisis  in  pneumonia,  the  increase,  however, 


Phospha  tes.  281 

not  usually  manifesting  itself  till  the  third  day  after 
fever  has  ceased,  and  also  in  cases  where  the  rapid 
absorption  of  a  large  exudation  is  taking  place. 

(2)  Phosphates. — Phosphoric  acid  occurs  in  the 
urine  in  two  chief  forms  of  combination.  Combined 
with  potassium,  sodium,  and  ammonium,  it  forms  the 
alkaline  phosphates  ;  with  calcium  and  magnesium  the 
earthy  phosphates.  Three-fourths  of  the  total  phos- 
phoric acid  is  combined  with  the  alkalies  and  only 
one-fourth  with  the  earths.  The  alkaline  phosphates 
being  readily  soluble  never  form  a  deposit.  The 
earthy  phosphates  are  insoluble  in  an  alkaline  medium, 
hence  they  are  precipitated  when  the  urine  loses 
its  acid  reaction.  This  precipitation  is  aided  by  the 
action  of  heat.  The  heat  probably  acts  by  driving  off 
carbonic  acid.  Hence  if  a  urine,  the  reaction  of 
which  is  not  acid,  be  heated,  a  cloud  of  earthy  phos- 
phates may  appear.  This  is  distinguished  from  albu- 
min by  its  ready  disappearance  on  a4ding  a  few 
drops  of  acetic  acid. 

Qualitative  tests  for  lyhosphoric  acid  in  urine. — 
Place  half  an  inch  of  clear  urine  in  a  test  tube.  Add 
a  few  drops  of  a  solution  of  uranium  acetate  or 
nitrate  and  a  little  sodium  acetate  solution  (Appendix, 
11).  A  somewhat  greenish  precipitate  which  does  not 
disappear  on  adding  acetic  acid  indicates  the  presence 
of  phosphates. 

Quantitative  estimation. — Fill  a  burette  with 
standard  solution  of  uranium  nitrate  (Appendix,  10). 
Measure  50  cc.  of  the  urine  to  be  examined  into  a 
porcelain  dish  or  a  medium-sized  beaker.  (If  the  urine 
is  very  concentrated,  20  cc.  of  it  will  be  sufficient.) 
Add  to  the  urine  5  cc.  of  an  acetic  acid  solution 
of  acetate  of  soda  (Appendix,  11).  If  only  20  cc. 
urine  were  taken,  add  2  cc.  of  the  solution.  Place  on 
a  Avhite  porcelain  slab  about  a  dozen  drops  of  a  10 
per  cent,  solution  of  ferrocyanide  of    potash.     Each 


282  The  Urine. 

drop  should  be  about  the  size  of  a  sixpence.  They 
should  be  deposited  in  regular  rows  a  short  distance 
apart.  Heat  the  urine  on  a  water  bath.  If  the 
latter  is  not  obtainable  use  a  tripod  covered  with  wire 
gauze.  The  urine  should  be  heated  to  a  temperature 
just  short  of  boiling.  When  heated,  run  in  the 
uranium  solution,  stirring  all  the  while.  As  a  rule, 
16  cc.  may  be  run  in  right  away.  A  precipitate  of 
uranium  phosphate  falls  down.  Take  out  a  small 
drop  of  the  mixture  with  a  glass  rod  and  place  it  just 
touching  one  of  the  drops  of  ferrocyanide.  If  the 
least  brown  colour  appears  at  the  point  of  junction 
of  the  drops  do  not  run  in  any  more  uranium  solution, 
but  heat  the  urine  up  again  to  just  short  of  boiling, 
and  try  another  drop.  If  still  a  faint  brown  tint 
appears,  enough  uranium  solution  has  been  added. 
The  brown  colour  indicates  that  all  the  phosphoric 
acid  present  has  united  with  the  uranium,  and  the 
latter  is  beginning  to  form  uranyl  ferrocyanide.  If 
the  colour  is  dark  brown,  too  much  uranium  has  been 
added.  One  must  then  add  5  cc.  more  urine  to  the 
mixture,  heat  up,  and  cautiously  run  in  more  uranium 
solution.  If  no  brown  tint  has  appeared  after  run- 
ning in  16  cc.  of  the  uranium,  one  must  add  more  of 
it,  but  slowl}^,  and  not  more  than  half  a  cc.  at  once, 
testing  a  small  drop  after  each  addition  till  the  faint 
brown  tint  appears.  If  the  urine  has  cooled  at  all 
while  one  is  adding  the  uranium,  never  omit  to  heat 
it  up  again  before  deciding  that  the  brown  tint  is 
really  present.  It  is  only  at  a  temperature  just  short 
of  boiling  that  all  the  phosphoric  acid  can  be  made  to 
unite  with  the  uranium.  The  use  of  the  acetate  of 
soda  in  the  above  process  is  to  unite  with  the  nitric 
acid  liberated  by  the  union  of  the  uranium  with  the 
phosphoric  acid. 

Calculation. — Suppose    20    cc.    uranium    solution 
has  been  required.     The  solution  was  made  of  such 


Sulphates.  283 

a  strength  that  each  cc.  =  5  milligrammes  plios- 
j)horic  anhydride ;  20  cc.  are  therefore  equivalent  to 
0*1  gramne  PoO-,  and  that  is  the  amount  in  50  cc. 
urine.  If  the  patient  is  passing  1,500  cc.  urine  in 
twenty-four  hours,  his  daily  excretion  of  PoO^  will 
be  3  grms. 

Normally,  2-3  grms.  of  phosphoric  anhydride 
are  excreted  daily.  Physiological  variations  depend 
chiefly  upon  the  food.  The  phosphates  are  often 
considerably  diminished  in  renal  disease,  but  not, 
apparently,  out  of  proportion  to  the  other  solids  of 
the  urine.  They  are  said  to  be  increased  in  wasting 
diseases  of  the  nervous  system.  Their  behaviour  in 
fever  is  inconstant. 

(3)  Sulphates. — Sulphuric  acid  occurs  in  the 
urine  in  combination  with  sodium  and  potassium 
(inorganic  sulphates),  and  with  cresol,  phenol,  indol, 
skatol,  pyrocatechin,  etc.  (organic  sulphates).  The 
former  are  ten  times  more  abundant  than  the 
latter. 

Test  for  inorganic  sulphates. — Add  to  10  cc.  urine 
a  few  drops  of  hydrochloric  acid  and  one-third  of  its 
volume  of  10  per  cent,  barium  chloride  solution.  If 
the  normal  amount  of  sulphates  is  present,  an 
opaque  milkiness  develops.  If  the  precipitate  is  thick 
and  creamy,  the  sulphates  are  in  excess ;  if  a  mere 
opalescence  appears,  they  are  diminished. 

About  2|^  grms.  of  sulphuric  acid  (SOg)  are 
excreted  daily.  The  exact  determination  of  the  total 
sulphates,  and  of  the  proportion  of  inorganic  to 
organic,  is  a  gravimetric  process  unsuited  for  ordinary 
clinical  work. 

An  approximate  notion,  however,  of  the  proportion 
of  organic  sulphates  present  may  be  obtained 
by  the  following  procedure :  Add  to  the  urine  an 
equal  volume  of  alkaline  barium  chloride  solution  (two 
parts  of  baryta  water  to  one  part  of  barium  chloride 


284  The   Urine. 

solution).  This  precipitates  the  inorganic  sulphates 
along  with  phosphates.  Filter.  Render  the  filtrate 
pretty  strongly  acid  Avith  hydrochloric  acid,  and  heat 
almost  to  boiling.  The  organic  sulphates  are  thus 
decomposed  and  thrown  down  in  the  inorganic  form. 
Normally  they  should  form  merely  a  white  cloud.  If 
the  precipitate  is  at  all  dense,  the  proportion  of 
organic  sulphate  is  in  excess. 

The  total  sulphates  are  increased  by  an  increase 
in  the  diet,  and  in  fever.  The  amount  of  sulphuric 
acid  excreted  in  organic  combination  is  increased 
when  a  larger  quantity  than  usual  of  the  aromatic 
substances  with  which  it  is  combined  enters  the 
circulation.  This  occurs  when  phenol  and  allied 
substances  are  given  as  drugs,  or  when  the  production 
of  such  substances  in  the  body  is  increased,  as  it  is 
whenever  putrefactive  processes  are  going  on.  Thus 
the  amount  of  organic  sulphates  is  increased  in  cases 
where  putrid  abscesses  have  formed,  or  where  there  is 
retention  of  the  intestinal  contents. 

(4)  Oxalates. — Oxalic  acid  occurs  in  the  urine, 
combined  with  calcium.  The  salt  is  usually  kept  in 
solution  by  the  acid  phosphate  of  sodium  present  in 
the  urine.  It  is  found  as  a  precipitate,  however,  in 
about  one  urine  out  of  every  three.  This  is  due  to 
the  absence  of  a  sufficient  amount  of  the  phosphate  of 
soda  to  keep  it  in  solution.  It  does  not  necessarily 
mean  that  the  excretion  of  oxalic  acid  is  increased, 
although  it  is  true  that  the  more  oxalic  acid  there 
is  present,  the  greater  is  the  tendency  for  it  to  be 
precipitated.  About  0"017  grm.  is  the  average 
amount  of  oxalic  acid  excreted  daily.  It  is  prob- 
ably all  derived  from  the  food.  It  is  increased 
after  the  taking  of  certain  vegetables,  especially 
cabbage,  tomatoes,  and  rhiibarb.  The  so-called 
"oxaluria"  seems  to  be  merely  a  variety  of  acid 
dyspepsia. 


Nitrogen.  285 

3.  Examination  of  the  urine  for  its 
normal  nitrog^enous  constituents. 

Of  the  total  amount  of  nitrogen  in  the  urine — 

84-87%  is  in  the  form  of  urea ; 
2-5%         ,,  ,,         ammonia  compounds ; 

1-  3%  ,,  ,,  uric  acid ; 

7-10%         „  „  "extractives" 

(including  xanthin  bases). 

Estimation  of  total  nitrogen  hy  KjeldahVs  method 
(modified). — Measure  out  5  cc.  of  urine  with  a 
pipette  and  place  it  in  a  Kjeldahl's  flask  of  about 
150  cc.  capacity,  add  to  it  15  cc.  of  pure  sulphuric 
acid  and  a  crystal  of  pure  sulphate  of  copper  about 
the  size  of  a  split  pea ;  heat  on  net  till  the  mixture  is 
colourless  or  pale  green ;  this  takes  about  half  an  hour 
or  less  ;  violent  boiling  should  be  avoided.  Allow  to 
cool,  then  dilute  with  50  cc.  of  distilled  water,  again 
allow  to  cool,  transfer  to  a  distillation  flask  of  about 
7uO  cc.  capacity,  and  add  enough  23%  solution  of  caus- 
tic soda  to  render  the  mixture  almost  neutral ;  add  also 
a  pinch  of  talc  to  prevent  bumping.  When  cool  add 
more  soda  (till  the  fluid  is  deep  blue  in  colour),  and 
close  at  once  with  the  stopper  connected  to  the  con- 
densing tube  of  the  distillation  apparatus ;  measure 
into  a  flask  150  cc.  of  a  decinormal  solution  of  oxalic 
acid,  and  let  the  lower  end  of  the  condensing  tube 
just  dip  below  the  surface  of  this  solution,  then  boil 
the  blue  fluid.  The  nitrogen  passes  off'  in  the  form  of 
ammonia  and  is  fixed  by  the  oxalic  acid.  When  the 
fluid  which  drops  from  the  condenser  has  no  longer 
an  alkaline  reaction,  stop  the  process  by  removing  the 
stopper  from  the  flask.  Care  must  be  taken  that  at 
the  end  no  alkali  comes  over  from  the  flask  contain- 
ing the  strongly  alkaline  fluid,  as  is  rather  apt  to 
occur  should  there  be  bumping.  Titrate  the  100  cc. 
of   decinormal   oxalic   acid   with   a   decinormal  soda 


286  The  Urine. 

solution.     Every  cc.  of  soda  less  than  a  hundred  used 
represents  "0014  grm.  of  nitrogen. 

Example. — Suppose  that  on  titrating  the  oxalic 
acid  solution  with  decinormal  soda  the  neutral  point 
is  reached  when  60  cc.  of  the  latter  have  been  added, 
the  remaining  40  cc.  of  the  decinormal  oxalic  taken 
must  therefore  have  been  neutralised  by  tlie  ammonia 
derived  from  the  nitrogen  in  the  5  cc.  of  urine,  there- 
fore the  5  cc.  of  urine  contain  '0014x40  grms. 
nitrogen,  or  -056  grm.  If  the  total  amount  of  urine 
passed  in  24  hours  be  1500  cc,  this  will  contain  16 "8 
grms.  of  nitrogen. 

About  15 '20  grms.  of  nitrogen  are  excreted  daily 
in  the  urine  of  a  healthy  adult  on  ordinary  diet.  A 
knowledge  of  the  quantity  excreted  in  disease  is  not 
of  much  value  unless  one  has  some  idea  of  the  amount 
of  nitrogen  in  the  diet.  It  must  be  remembered  also 
that  normally  1-2  grms.  of  nitrogen  appear  in  the  faeces. 
Urea  (Co(NH2)o). 

Qualitative  test  for. — Place  a  drop  or  two  of  the 
suspected  fluid  on  a  slide  and  add  one  drop  of  nitric 

acid,  warm  gently.  On 
evaporation  rhombic  or 
hexagonal  crystals  of  ni- 
trate of  urea  will  be  found 
if  the  latter  body  is  present. 
(Fig.  81).  _ 

Quantitative      Estima- 

Pig.  81. — Urea  nitrate.  tlOTl. 

1.  From  the  sj^ecijic 
gravity. — An  approximate  estimation  of  the  amount 
of  urea  may  be  made  by  dividing  the  last  two 
figures  of  the  specific  gravity  by  10 — e.g.  if  the 
specific  gravity  of  a  given  urine  be  1020  it  contains 
(approximately)  2^  of  urea,  this  only  holds  good  in 
the  absence  of  sugar,  or  much  albumin,  and  if  the 
patient  be  not  very  feverish. 


Urea.  287 

2.  From  the  amount  of  nitrogen  given  off  on 
treating  the  urine  ivith  hyjjohromite  of  soda. 

This  method  depends  upon  the  fact  that  urea 
is  decomposed  by  hypobromite  of  soda  according  to 
the  following  equation  —  CO(NH,)o  +  3NaBrO  =: 
3NaBr  +  No  +  2HoO  +  COo.  It  is" found  that  under 
ordinary  conditions  1  gramme  of  urea  yields  371  cc. 
of  nitrogen ;  all  that  is  necessary,  therefore,  is  to 
remove  the  CO^  by  means  of  an  alkali  (caustic  soda), 
and  to  measure  the  remaining  volume  of  gas  and 
to  calculate  from  it  the  amount  of  urea  which  was 
contained  in  the  quantity  of  urine  taken.  The 
various  forms  of  apparatus  employed  in  carrying  out 
the  process  differ  chiefly  in  the  method  adopted  for 
catching  and  measuring  the  nitrogen  given  ofif.  One 
of  the  earliest  and  simplest  consists  in  receiving  the 
gas  in  an  ordinary  burette  inverted  in  a  large  jar  of 
water. 

The  number  of  cc.  of  nitrogen  given  off  multiplied 
by  0  056  =  grms.  of  urea  in  100  cc.  urine,  i.e.  the 
percentage,  and  this  multiplied  by  4-375  =  grains  of 
urea  in  1  oz.  of  urine. 

More  commonly  nowadays  one  makes  use  of  one 
or  other  of  the  following  special  forms  of  apparatus  : — 

(1)  GerrardJs  ureometer  (Fig.  82). — This  consists 
of  a  graduated  glass  cylinder  closed  at  its  upper  end 
by  a  rubber  stopper.  Through  the  stopper  there  passes 
a  T  tube.  One  limb  of  this  tube  is  closed  by  a  clip  or 
stopcock,  the  other  is  connected  to  a  piece  of  rubber 
tubing.  The  other  end  of  the  rubber  tubing  terminates 
in  a  piece  of  glass  tube,  which  is  inserted  into  the 
rubber  stopper  of  a  wide-mouthed  flask  of  about  6  oz. 
capacity.  From  the  lower  end  of  the  graduated 
C5dinder  another  rubber  tube  passes  to  a  short  wide 
glass  tube  open  at  its  upper  end.  The  object  of  this 
tube  is  to  act  as  a  reservoir  of  water.  It  can  be  slipped 
up  and  down  upon  the  cylinder  by  means  of  a  metal  ring. 


288  The  Urine. 

How  to  use  the  aiofaratus. — Place  in  the  glass 
flask  25  cc.  of  hypobromite  solution  (Appendix, 
12).  An  excess  of  hypobromite  does  no  harm — 
one   must   merely   be   sure    that    enough    is   taken 


Fisf.  82. — Genard's  ureometer. 


to  decompose  all  the  urea  likely  to  be  found  in 
the  urine.  Measure  5  cc.  of  urine  into  the  small 
glass  tube  provided  for  the  purpose.  If  the  urine 
contains  albumin,  the  latter  must  be  first  removed. 
This  is  best  done  by  taking  a  definite  quantity  of 


Urea.  289 

urine — say,  50  cc— adding  to  it  a  drop  or  two  of 
acetic  acid,  and  boiling  for  a  couple  of  minutes. 
Filter  and  make  up  to  its  original  volume. 

The  small  tube  containing  the  urine  must  now  be 
lowei'ed  into  the  flask.  This  is  best  done  b}^  inserting 
the  point  of  the  little  finger — not  too  tightly — into 
the  mouth  of  the  tube.  The  latter  must  then  be 
propped  up  against  the  inner  surface  of  the  flask  so 
as  to  prevent  the  hypobromite  solution  from  mixing 
with  the  urine.  The  reservoir  of  the  graduated 
cylinder  must  now  be  filled  M'ith  water.  The  stopper 
is  then  tightly  inserted  into  the  mouth  of  the  flask. 
The  clip  or  stopcock  must  now  be  opened,  and  the 
reservoir  raised  until  the  water  inside  the  cylinder 
stands  at  the  zero  mark,  and  is  level  with  that  in  the 
reservoir.  The  water  must  also  be  very  low  down  in 
the  latter,  else  there  will  be  an  overflow  subsequently. 
Now  close  the  stopcock  and  gently  tilt  the  flask  so  as 
to  allow  the  urine  and  hypobromite  solution  to  mix. 
Great  eflfervescence  ensues,  and  the  nitrogen  liberated 
enters  the  cylinder  and  drives  water  out  of  it  up  into 
the  reservoir.  Wait  for  ten  minutes  to  allow  coolins; 
to  take  place.  Then  lower  the  reservoir  until  the 
water  in  it  and  the  cylinder  are  again  level,  and  read 
off  the  amount  of  gas  in  the  latter.  The  cylinder  is 
graduated  in  percentages  of  urea.  To  get  the  number 
of  grains  per  ounce,  multiply  this  by  4*375. 

In  normal  urine  only  92  per  cent,  of  the  nitrogen 
of  the  urea  is  given  off.  If  sugar  be  present,  the  yield 
is  for  some  reason  much  larger,  amounting  to  about 
99  per  cent.  In  Gerrard's  instrument  the  scale  is 
constructed  for  normal  urine.  In  cases  of  diabetes, 
therefore,  it  is  necessary  to  correct  one's  result  by 
multiplying  the  flgure  obtained  by  ff,  i.e.  by  0-93. 

(2)   Ureometer  of  Dor  emus. 

This  is  a  very  simple  and  cheap  form  of  apparatus, 
devised  by  Dr.  Chas.  Doremus  of  New  York,     Modi- 

T 


290  The  Urine. 

fications  of  it  are  sold  by  Southall  (Birmingham)  and 
Cooper  (London),  It  consists  of  a  bent  tube  with  a 
long  limb  closed  at  its  upper  end,  and  a  short  limb 
which  expands  into  a  wide  bulb  with  an  open  mouth. 

In  using  the  instrument  it  must  first  be  filled 
with  hypobromite  solution.  Hold  the  tube  vertically, 
and  pour  in  the  solution  just  short  of  overflowing. 
Then  gently  incline  the  instrument  so  that  the  solu- 
tion fills  the  long  limb  as  far  as  the  mark  near  the 
bend,  and  no  air  bubbles  are  present.  A  little  water 
should  then  be  added  to  fill  the  rest  of  the  bend  and 
the  lower  part  of  the  bulb.  The  instrument  may 
now  be  fixed  in  its  stand. 

One  cc.  of  urine  has  next  to  be  measured  out  with 
the  pipette  provided.  This  is  where  the  difficulty  in 
using  the  instrument  comes  in.  In  order  to  accom- 
plish it  successfully,  proceed  as  follows  : — Slip  the 
rubber  nipple  high  up  upon  the  pipette.  Compress 
the  nipple,  and  immerse  the  point  of  the  pipette  just 
below  the  surface  of  the  urine.  Then  allow  the 
nipple  to  expand  fully.  Urine  will  be  drawn  up 
beyond  the  mark.  Now  slide  the  nipple  bodily  down 
with  the  finger  and  thumb  over  the  rimmed  end  of 
the  pipette.  This  displaces  the  urine.  Continue  the 
displacement  till  the  mark  is  reached.  The  pipette 
will  now  keep  itself  charged  with  exactly  1  cc.  of 
urine.  Wipe  the  outer  surface  of  the  pipette,  and 
insinuate  the  end  of  it  as  far  as  it  will  go  into  the 
long  limb  of  the  apparatus.  Now  compress  the 
nipple  so  as  to  squeeze  out  all  the  urine,  and  then 
withdraw  the  pipette,  keeping  up  the  compression 
until  it  is  out  of  the  liquid. 

In  about  a  quarter  of  an  hour  the  amount  of 
nitrogen  which  has  collected  in  the  long  limb  may 
be  read  off".  The  instrument  is  provided  with  an 
English  scale  representing  grains  per  ounce,  and  also 
with  a  metrical  scale.     The  large   divisions  on    the 


Uric  Acid.  291 

latter  represent  centigrams  of  urea  per  cc.  of  urine. 
The  scale  between  is  subdivided  into  tenths.  Suppose 
the  reading  to  be  *025.  This  means  -025  grm.  of 
urea  in  1  cc.  of  urine,  and,  multiplying  by  100,  =  2-5 
per  cent.  If  more  than  3  per  cent,  of  urea  is  present, 
the  urine  should  be  diluted  with  an  equal  volume  of 
water,  and  the  result  multiplied  by  2.  Albumin,  if 
present,  should  always  be  removed  beforehand. 

About  450  grains  (25-40  grms.)  of  urea  are 
excreted  daily  in  health.  This  is  about  2  per  cent., 
or  9  grains  per  ounce.  It  is  increased  when  much 
food  or  water  is  taken.  Also  in  fevers,  in  diabetes, 
and  in  poisoning  by  phosphorus  or  arsenic.  It 
diminishes  under  diminished  diet,  in  some  severe 
diseases  of  the  liver  (because  less  is  formed),  and  in 
some  conditions  of  the  kidney. 

ITric  acid  (C-H.N-O..)  occurs  in  the  urine  in 
combination  with  alkalies.  Being  a  dibasic  acid,  it 
forms  two  classes  of  salts,  the  normal  urates  (XaoU), 
and  the  acid  urates  (NaHU).  In  addition,  it 
seems  to  form  a  third  kind  of  combination  in  which 
one  molecule  of  acid  urate  is  united  to  one  of  uric 
acid,  constituting  what  ma\'  be  called  a  quadri-urate 
(NaHUHoU).  According  to  some  observers,  it  is 
the  latter  form  of  combination  which  occurs  in 
normal  urine,  and  which  is  sometimes  precipitated  in 
the  form  of  the  common  "  brick  dust ''  deposit  of  urates 
or  "lithates."  Under  certain  conditions  uric  acid 
becomes  free  in  the  urine,  and  separates  out  as  a 
crystalline  deposit  ("cayenne-pepper'"'  deposit).  Acid 
urates  may  also  separate  out  in  a  crystalKne  form. 
Both  forms  of  separation,  when  occurring  inside  the 
urinary  passages,  lead  to  the  disease  known  as  "gravel  ' 
or  to  stone  fonnation.  The  microscopic  characters  of 
these  deposits  will  be  described  in  another  section. 
The  conditions  which  favour  the  separation  of  uric 
acid  and  acid  urates  are  (1)   the  presence  of  a  large 


292  The   Urine. 

amount  of  uric  acid  in  the  urine ;  (2)  a  high  degree  of 
acidity ;  (3)  the  presence  of  little  salts,  and  of  a  small 
amount  of  pigment. 

Qualitative  test  for  uric  acid  (murexide  test). — 
Evaporate  the  suspected  fluid  to  a  small  bulk.  Place 
five  drops  of  it  in  a  porcelain  basin,  and  add  one 
drop  of  nitric  acid.  Evaporate  very  slowly,  avoid- 
ing charring.  When  almost  dry,  add  to  the  orange- 
coloured  residue  a  small  drop  of  ammonia.  A  pur- 
plish or  rosy  red  colour  appears  at  the  edge  of  the 
drop,  often  better  seen  after  gently  heating. 

The  action  which  takes  place  consists  in  the 
oxidation  of  the  uric  acid  into  alloxantine  (CgHgN^Og) 
— the  orange- coloured  residue.  On  adding  ammonia, 
purpurate  of  ammonia  is  formed  (JSTHj^CgH^JSTgOg),  and 
produces  the  purplish  red  colour. 

Quantitative  estir)iation. — For  clinical  purposes 
this  is  best  accomplished  by  the  method  proposed 
by  Hopkins.  It  is  based  upon  the  insolubility  of 
acid  urate  of  ammonia  in  a  saturated  solution  of 
ammonium  chloride.  By  saturating  a  given  quantity 
of  urine  with  chloride  of  ammonium,  all  the  uric 
acid  separates  out  as  acid  urate  of  anmionium,  which 
is  collected  ;  the  uric  acid  is  then  split  off  from  it, 
and  estimated  either  by  weighing  or  by  titration  with 
permanganate  of  potash.     Proceed  as  follows  : — 

(1)  Saturate  100  cc.  of  urine  with  powdered 
ammonium  chloride.  About  30  grms.  will  be  re- 
quired. Saturation  is  complete  whenever  a  few 
crystals  remain  undissolved  after  vigorous  stirring  at 
short  intervals.  Even  if  these  should  redissolve  as 
the  temperature  of  the  mixture  risps  again  after  its 
initial  depression,  it  does  not  matter. 

(2)  Render  alkaline  by  adding  a  little  ammonia. 

(3)  After  standing  for  ten  minutes,  filter  and 
wash  precipitate  several  times  with  saturated  solu- 
tion of  ammonium  suljohate. 


Uric  Acid.  293 

(4)  Wash  precipitate  off  filter  with  a  jet  of  hot 
water,  add  a  pinch  of  carbonate  of  soda,  and  heat  till 
precipitate  dissolves. 

(5)  Add  distilled  water  to  100  cc. 

(6)  Add  20  cc.  strong  sulj^huric  acid. 

(7)  While  hot,  titrate  with  a  J^  normal  solution 
of  potass,  permanganate — i.e.  1"578  grm.  per  litre. 

(8)  Stop  whenever  a  j^ink  colour  lasting  a  few 
seconds  has  appeared.  Subsequent  disappearance 
of  the  colour  is  to  be  disregarded  ;  it  is  sufficient  that 
it  should  be  visible  for  a  second  or  two  after  stirring. 

(9)  Every  cc.  of  the  permanganate  used  =:  0 '00375 
grm,  of  uric  acid. 

The  presence  of  bile  pigment  interferes  with  the 
titration  with  permanganate.  In  that  case  the  uric 
acid  must  be  estimated  by  weighing,  and  for  the 
details  of  the  method  we  must  refer  the  reader  to  the 
original  paper.*  The  trouble  in  the  above  method  is 
the  washing  with  ammonium  sulphate.  This  must  be 
continued  till  all  ammonium  chloride  is  removed,  but 
the  solution  is  so  dense  that  it  passes  very  slowly 
through  the  filter  paper.  To  obviate  this  difficulty^ 
Hopkins  has  described  an  abbreviation  of  the  pro- 
cess which  is  accurate  enough  for  clinical  purposes. 
It  is  as  follow^s  : — 

(1)  Saturate  20  cc.  of  urine  with  chloride  of 
ammonium,  and  add  ammonia,  as  above. 

(2)  Place  a  plug  of  glass  wool  in  the  neck  of  a 
small  funnel,  and  Avash  it  by  filtering  through  it  some 
saturated  ammonium  sulphate  solution. 

(3)  After  the  saturated  urine  has  stood  for  ten 
minutes,  filter  it  through  the  glass  wool.  (A  little 
experience  is  necessary  to  enable  one  to  pack  the 
glass  w^ool  firmly  enough  to  keep  back  the  pre- 
cipitate, but  yet  not  so  tightly  as  to  render  filtration 
very  slow.) 

*  Journal  of  Pathology  and  Bacteriology,  June,  1893. 


294  The   Urine. 

(4)  Wash  the  precipitate  with  saturated  sulphate 
of  ammonium  till  no  more  chloride  comes  away. 

(5)  Transfer  plug  and  precipitate  bodily  to  a 
flask.  Add  20  cc.  water  and  a  small  pinch  of 
carbonate  of  soda.  Heat  till  the  urate  dissolves. 
Cool  under  the  tap,  and  add  4  cc.  of  strong  sulphuric 
acid. 

(6)  Titrate  with  J^j  normal  permanganate  solution, 
as  above.  (This  is  best  made  by  diluting  some  of  the 
strong  solution  from  time  to  time.) 

(7)  Every  cc.  of  the  permanganate  used  =  0-0015 
grm.  uric  acid. 

The  presence  of  albumin  does  not  affect  these 
methods.  If  there  be  a  deposit  of  uric  acid  or  urates 
in  the  sample  of  urine,  the  whole  should  be  thoroughly 
shaken  up,  the  amount  to  be  operated  with  measured 
off",  and  saturated  as  usual.  Or  a  few  drops  of 
ammonia  may  be  added  and  the  urine  warmed  till  the 
deposit  dissolves.  A  deposit  of  phosphates  may  be 
neglected. 

From  0-4  to  0.7  grm.  (7-10  grains)  of  uric  acid  is 
excreted  daily.  The  amount  is  increased  whenever  a 
large  destruction  of  nuclein  is  going  on ;  thus  in 
leucocythsemia  as  much  as  4  grms.  may  be  excreted 
daily.  It  is  also  increased  in  acute  fevers.  It  is 
diminished  in  chronic  gout  and  after  the  administra- 
tion of  quinine. 

We  would  again  warn  the  reader  against  the 
common  error  of  assuming  that  a  deposit  of  urates  or 
uric  acid  necessarily  indicates  an  increased  excretion 
of  the  latter. 

Xantliin  bases. — Amongst  the  chief  products 
of  the  disintegration  of  nuclein  are  uric  acid  and 
some  basic  bodies  which  may  be  termed  the 
"nuclein"  or  xanthin  bases.  These  substances  differ 
from  uric  acid  in  being  pretty  strongly  basic.  Xanthin 
is  the  chief  member  of  the  group.     It  has  the  formula 


o 


X A  NTH  IN  Bases.  295 

CjH^N^Oo — i.e.  one  atom  of  oxygen  less  than  in 
uric  acid.  The  other  members  are  hypoxanthin  or 
sarkin  (C-H^N^O),  guanin  (C5H5N-O),  and  adenin 
(C-H5N5-I-3H0O).  These  bases  are  sometimes 
spoken  of  along  with  uric  acid  under  the  term 
"alloxur  bodies.'  These  alloxur  bodies  contain 
between  them  from  1-5  per  cent,  of  the  total  nitrogen 
in  the  urine.  A  method  has  been  de.scribed  for 
estimating  them,"^  but  it  is  not  adapted  for  ordin- 
ary clinical  use,  nor  has  its  accuracy  ))een  fully 
established.  The  results  Avhich  it  has  yielded  show 
that  the  amount  of  nitrogen  eliminated  in  the  form 
of  uric  acid  is  much  more  constant  than  that  which 
appears  in  the  form  of  xanthin  bases.  Usually  a 
good  deal  more  of  the  former  is  eliminated  than  of 
the  latter,  but  the  proportions  vary  greatly  even  in 
health,  and  may  at  times  even  be  reversed.  The 
xanthin  bases  are  increased  just  as  uric  acid  is 
in  conditions  associated  with  increased  destruction 
of  nuclein — e.g.  in  leucocyth^emia.  A  milk  diet 
causes  the  bases  to  increase  while  the  uric  acid 
diminishes.  There  is  no  constancy  in  their  behaviour 
in  gout. 

The  only  other  nitrogenous  constituents  of  normal 
urine  which  call  for  mention  are  creatinin  and 
hippuric  acid. 

€r  eat  mill — C^H-NgO — is  creatin  minus  water. 
It  is  one  of  the  forms  in  which  creatin  is  excreted,  and 
most  of  it  is  derived  from  the  creatin  in  flesh  food. 
About  1  grm.  of  it  is  excreted  daily.  Variations 
are  of  no  known  clinical  siofnificance.  It  is  of  some 
importance  as  being  one  of  the  constituents  of  normal 
urine,  which  is  able  to  reduce  cupric  oxide. 

Hippuric  acid — -CgHglSrO.. — occurs  in  the  urine 
as  hippurate  of  sodium.  About  ^  grm.  of  it  is  ex- 
creted daily.  This  amount  is  increased  by  the  taking 
*  Ztsch.  f.  Phys.  Chemie,  Bd.  xx.     Ki'iiger-TVulff. 


296  The  Urine. 

of  benzoic  acid  as  a  drug,  or  of  fruits — e.g.  mulberries 
and  cranberries — which  contain  aromatic  acids. 

4.  Abnormal  cliemical  constituents  of 
Mi'ine. 

I.— PROTEIDS. 

Any  or  all  of  the  proteids  of  blood  plasma — 
serum  albumin,  serum  globulin,  and  fibrinogen — 
may  occur  in  the  urine.  In  addition,  one  meets 
with  the  compound  proteids — mucin  and  nucleo- 
albumin,  and  with  albumoses,  both  primary  and 
secondary.  It  is  doubtful  whether  true  peptone  ever 
occurs  in  the  urine.  It  is  true  that  two  of  these — 
mucin  and  nucleo-albumin — are  to  be  regarded  as 
normal  urinary  constituents,  being  added  to  the  renal 
secretion  as  it  passes  along  the  urinary  passages,  but 
in  health  they  are  present  in  such  small  amount  that 
they  may  be  neglected.  It  is  also  true  that  any  of 
the  proteids  mentioned  above  may  occasionally  find 
their  way  into  the  urine  even  in  perfectly  healthy 
persons.  Into  the  possible  causes  of  this,  and  into 
the  distinction  between  "  functional  "  and  "  organic  " 
albuminurias,  we  do  not  propose  to  enter.  Chemical 
examination  of  the  urine  can  merely  show  the  presence 
in  the  urine  of  a  proteid ;  it  cannot  tell  us  to  what  its 
presence  is  due. 

(1)  ^erum  albumin  and  serum  g^lobulin  in 
the  urine. — These  proteids  may  be  found  in  the 
urine  either  together  or  separately.  The  former 
condition  is  the  usual  one,  and  constitutes  what  is 
ordinarily  spoken  of  as  "albuminuria."  The  relative 
proportion  of  each  proteid  varies  greatly  in  different 
cases,  but  usually  serum  albumin  is  present  in  larger 
amount  than  serum  globulin.  The  variations  in  their 
relative  amounts  have  no  clinical  significance.  In 
what  follows  the  term  "  albumin "  will  be  held  to 
include  also  globulin,  unless  stated  otherwise. 


Proteids  in  the   Urine.  297 

Tests  for  alhumin  in  the  urine. — A  great  many 
reactions  have  been  proposed  for  this  purpose,  and 
much  has  been  written  on  the  subject.  The  fact 
seems  to  be  that  while  in  the  majority  of  cases  the 
presence  of  albumin  or  globulin  in  the  urine  can  be 
demonstrated  with  perfect  certainty  by  the  appli- 
cation of  one  or  two  simple  tests,  yet  every  now  and 
then  cases  are  met  with  in  which  some  doubt  exists. 
We  believe  that  by  carefully  applying  the  four  fol- 
lowing tests  the  presence  of  albumin  and  globulin 
can  be  cleaily  shown  even  when  present  in  very  small 
amount.  Before  proceeding  to  apply  any  of  the  tests, 
it  is  a  sine  qud  non  that  the  urine  should  be  ahso- 
lutely  clear.  It  may  therefore  be  necessary  to  filter 
it.  If  it  be  acid,  this  can  be  proceeded  with  at  once  ; 
should  it  be  alkaline,  enough  acetic  acid  should  first 
be  added  to  render  it  faintly  acid.  It  may  be  necessary 
to  fi.lter  more  than  once.  Should  the  urine  still  not 
be  clear,  the  turbidity  is  probably  occasioned  by  the 
presence  of  bacteria.  These  can  best  be  removed 
either  by  (1)  simply  shaking  up  the  urine  with 
powdered  barium  carbonate,  and  filtering,  or  (2) 
adding  to  the  urine  a  little  caustic  soda  till  a  pre- 
cipitate of  earthy  phosphates  appears.  This  carries 
down  with  it  all  bacterial  debris,  and  on  filtering  the 
urine  will  now  be  found  to  be  clear.  It  should  then 
be  slightly  acidified  with  acetic  acid,  and  the  following 
tests  proceeded  with  : — 

1.  Boil  an  inch  or  so  of  the  urine  in  a  test  tube. 
If  it  remains  perfectly  clear  while  the  reaction  is  still 
acid,  no  albumin  is  present.  Turbidity  may  be  due  to 
coagulated  albumin  or  to  the  throwing  down  of  earthy 
phosphates.  Add  a  drop  of  nitric  acid.  Any  turbidity 
which  remains  is  due  to  the  presence  either  of  albumin 
or  of  nucleo- album  in. 

2.  Heller^ s  test. — Place  a  quarter  of  an  inch  of 
pure  nitric  acid  in  a  test  tube.     With  the  aid  of  a 


298  The   Urine. 

pipette  allow  some  of  the  urine  to  flow  on  to  its 
surface.  If  after  standing  for  half  a  minute  no 
opaque  white  ring  appears  at  the  junction  of  the  two 
fluids  the  urine  may  be  regarded  as  free  from  albumin, 
for  the  test  is  capable  of  revealing  the  presence  of 
•002  per  cent.  If  a  ring  forms  it  may  be  due  to 
albumin,  nucleo-alljumin,  or  primary  albumoses.  A 
difluse  haze  at  the  upper  part  of  the  fluid  may  be  due 
to  mucin.  In  the  case  of  albumoses  the  ring  disappears 
on  heating,  and  reappears  on  cooling.  (The  metliod 
of  distino-uishino-  nucleo-albumin  and  mucin  will  be 
considered  later.)  If  the  urine  be  very  concentrated, 
nitrate  of  urea  or  acid  urates  may  separate  out,  usually 
in  the  form  of  a  cloud  without  sharp  margins.  This 
can  at  once  be  distinguished  by  the  fact  that  previous 
dilution  of  the  urine  with  twice  its  volume  of  normal 
salt  solution  prevents  its  appearance.  The  precipitate 
also  disappears  on  heating,  and  shows  small  crystals 
on  examination  with  the  microscope.  The  presence 
of  resinous  bodies — e.g.  balsams — in  the  urine  may 
also  cause  the  appearance  of  a  white  cloud,  which, 
however,  is  at  once  dissolved  on  the  addition  to  the 
urine  of  half  its  volume  of  alcohol  (rectified  spirit). 

It  will  often  be  noticed  that  a  brownish  red  trans- 
parent ring  appears  at  the  junction  of  the  nitric  acid 
and  the  urine.  It  is  due  to  the  oxidation  of  the 
urinary  indigogens  and  the  production  from  them  of 
pigments.  It  occurs,  therefore,  in  urines  which  are 
rich  in  indigogens,  and  has,  of  course,  nothing  to 
do  with  albumin.  Such  urines  will  be  more  fully 
considered  later. 

Eflfervescence  on  the  addition  of  nitric  acid  may 
be  due  to  decomposition  of  urea  with  the  liberation  of 
COc,  and  nitrogen.  This  only  occurs  if  the  nitric  acid 
used  contains  some  nitrous  acid  also. 

As  a  substitute  for  nitric  acid  in  the  above  test, 
one  can  use',  Spiegler^s  s^ution,  j   It  coilsists  of — 


P ROTE  IDS    IN    THE    UrINE.  299 

Perchloricle  of  mercury  ...  ...        4  parts 

Tartaric  acid        ...  ...  ...        2     ,, 

Glycerine  ...  ...  ...      10     „ 

Water      100     „ 

It  gives  a  distinct  white  ring  if  as  little  albumin 
as  1  in  350,000  is  present. 

3.  Ferrocyanide  of  'potash  test. — Take  2  in.  of 
urine  in  a  test  tube.  Add  10  drops  of  a  5  per  cent, 
solution  of  ferrocyanide  of  potash,  and  then  render 
strongly  acid  witli  acetic  acid.  If  the  urine  remains 
clear,  no  albumin  is  present.  Turbidity  may  be  due 
to  albumin,  albumose,  or  nucleo-albumin.  Albumose 
may  be  distinguished  by  the  nitric  acid  test ;  nucleo- 
albumin  by  the  fact  that  it  is  precipitated  by  acetic 
acid  alone  without  the  aid  of  ferrocyanide. 

4.  Picric  acid  test.—  iJJsQ  a  saturated  solution  of 
pure  picric  acid,  without  the  addition  of  citric  acid, 
as  in  Esbach's  solution).  Place  2  in.  of  the  picric 
acid  in  a  test  tube.  Allow  the  urine  to  drop  into  it 
from  a  pipette.  If  no  cloud  forms  around  the  drops, 
the  urine  is  albumin-free.  A  cloud  may  be  due  to 
albumin,  albumoses,  or  peptone.  The  precipitate  pro- 
duced by  the  higher  albumoses  and  peptone  disappears 
on  heating.  Quinine  also  gives  a  precipitate  with 
picric  acid  which  disappears  on  heating. 

It  will  be  observed  from  what  has  been  said  above 
that  it  is  comparatively  easy  to  be  sure  of  the  absence 
of  albumin — not  so  easy  to  be  certain  of  its  presence. 
The  substance  which  is  most  apt  to  be  mistaken  for 
serum  albumin  in  the  urine  is  nucleo-albumin.  We 
have  already  indicated  some  methods  of  distinguishing 
between  the  two,  and  shall  return  to  the  subject  later 
when  we  consider  "  nucleo-albuminuria." 

Quantitative  estimation  of  alhumin. — This  can  be 
done  with  sufficient  accuracy  for  clinical  purposes  by 
means  of  Esbach's  albuminimeter.  The  principle  of 
the  method  consists  in  measuring  the  depth  of  the 


300  The   Urine. 

coagulum  produced  in  the  urine  by  the  addition  of 
picric  acid.  The  instrument  consists  of  a  thick  glass 
test  tube,  with  graduations  on  it  from  0  up  to  7. 

Method. — Filter  the  urine  if  not  already  clear, 
and  if  alkaline  render  slightly  acid  with  acetic  acid. 
If  the  specific  gravity  is  1010  or  more,  dilute  the  urine 
sufliciently  to  bring  the  density  below  that  level  (to 
1008).  This  is  important,  and  is  often  overlooked. 
Fill  the  tul)e  with  the  urine  up  to  the  mark  U.  Pour 
in  the  reagent  (Appendix,  13)  up  to  the  mark  R. 
Close  the  tube  with  a  rubber  stopper,  and  gently 
invert  it  a  few  times  to  allow  the  fluids  to  mix. 
Set  aside  for  twenty-four  hours.  At  the  end  of  that 
time  read  off  the  level  of  the  surface  of  the  pre- 
cipitate. The  figures  on  the  scale  represent  grammes 
of  dried  albumin  per  litre  of  urine. 

Divide  by  10  to  get  the  percentage,  and  multiply 
the  result  by  4-375  to  get  the  amount  of  albumin  in 
grains  per  ounce  of  urine.  If  the  urine  requires  to 
be  diluted,  the  result  must,  of  course,  be  multiplied 
the  requisite  number  of  times. 

Yery  small  quantities  of  albumin  cannot  be  esti- 
mated by  Esbach's  method,  as  the  instrument  does  not 
record  less  than  O'l  per  cent.  If  after  the  first  trial 
the  level  of  the  precipitate  is  found  to  be  above  the 
mark  7,  the  urine  must  be  diluted  and  a  fresh 
estimation  made. 

An  excretion  of  8  grms.  of  albumin  daily 
represents  an  ordinary  degree  of  albuminuria.  This 
is  equivalent  to  about  ^  per  cent. 

(2)  Albiimosuria. — This  is  a  more  correct  term 
than  "  peptonuria,"  which  was  formerly  in  use.  It  is 
very  doubtful  whether  true  peptone  ever  occurs  in  the 
urine  at  all.  The  clinical  significance  of  the  presence 
of  albumoses  in  the  urine  is  not  yet  finally  determined. 
Recent  investigations  tend  to  show  that  they  may 
occur   in   any    "  infective  "  disease — i.e.  wherever  dis- 


Proteids  in  the  Urine.  301 

integration  of  tissue  is  going  on  under  the  action  of 
micro-organisms.  Thus  they  are  not  uncommonly 
met  with  in  the  urine  in  pneumonia.  They  are  most 
constant,  however,  in  cases  where  a  large  collection  of 
pus  has  formed  in  the  body — e.g.  in  empyema  or  large 
abscess  formation.  They  have  also  been  found  in 
considerable  quantity  in  some  cases  of  nephritis.  The 
disease  osteomalacia  has  long  been  stated  to  be  accom- 
panied by  the  presence  of  albumoses  in  the  urine.  It 
is  doubtful  if  the  substance  met  with  is  really  an 
albumose,  and  it  is  also  doubtful  whether  the  cases 
examined  were  all  examples  of  true  osteomalacia. 

Detection  of  alhunioses. — There  are  two  classes  of 
albumoses — primary  and  secondary — the  latter  stand- 
ing nearest  to  the  peptones.  From  a  clinical  point  of 
view  the  differentiation  of  the  two  is  of  no  importance, 
but  they  differ  somewhat  in  their  chemical  reactions, 
and  this  necessitates  the  application  of  different  tests 
for  their  detection.  We  will  assume  first  that  the 
urine  to  be  examined  is  free  from  albumin.  Proceed 
as  follows  : — 

1.  Add  to  the  urine  (filtered  and  acidified  if 
necessary)  a  few  drops  of  a  saturated  solution  of 
picric  acid.  A  white  cloud  which  disappears  on 
heating  indicates  the  presence  of  either  albumoses 
or  peptone. 

The  presence  of  antipyrin,  quinine,  and  certain 
resins  in  the  urine  is  apt  to  give  a  similar  reaction. 

2.  Apply  Heller's  test  as  already  described  (p.  297). 
A  white  cloud  which  disappears  on  heating  and  re- 
appears on  cooling  indicates  the  presence  of  primary 
albumoses.  The  cloud  is  situated  towards  the  upper 
part  of  the  tube — it  does  not  form  a  sharp  ring  close 
to  the  nitric  acid  as  is  the  case  with  albumin.  The 
secondary  albumoses  do  not  give  this  reaction  unless  in 
the  presence  of  an  excess  of  salt. 

3.  Add  to  the  urine  an  equal  volume  of  a  saturated 


302  The   Urine. 

solution  of  common  salt,  and  then  drop  in  acetic  acid 
as  long  as  a  cloud  forms.  If  this  disappears  on  heat- 
ing and  reappears  on  cooling  albumoses  are  present. 
Both  forms  of  albumose  give  this  reaction. 

If  the  urine  is  already  albuminous  the  albu- 
min should  be  removed  before  testing  for  albumose. 
To  do  this  bring  the  urine  to  boiling  point,  add  a  drop 
or  two  of  acetic  acid,  and  boil  for  two  minutes.  Filter 
and  test  filtrate  as  above.  The  small  quantity  of 
albumose  likely  to  be  formed  from  the  albumin  during 
the  boiling  does  not  vitiate  the  result.  If  we  wish 
to  avoid  the  possibility  of  such  a  fallacy,  we  can  add  to 
the  urine  its  own  volume  of  10  per  cent,  trichloracetic 
acid,  rapidly  bring  to  the  boil,  and  filter  hot.  Test 
the  filtrate,  after  cooling,  for  albumoses. 

If  the  presence  of  true  peptone  be  suspected,  the 
urine  must  be  saturated  while  boiling  with  sulphate 
of  ammonium  and  the  filtrate  tested  for  peptone  by 
the  ordinary  reactions — the  best  being  the  occurrence 
of  a  white  ring  on  pouring  Spiegler's  solution  on  to 
the  surface  of  the  liquid ;  or,  better,  dialyse  the  urine 
for  two  hours  and  test  the  dialysate  for  peptone.  No 
albumose  passes  through  in  that  time.  Very  delicate 
reactions  for  the  presence  of  albumoses  and  peptones 
in  the  urine  have  been  described  by  Salkowski*  and 
by  Harris,!  and  may  be  referred  to  by  those  who  are 
specially  interested  in  the  subject.  We  have  had 
no  personal  experience  of  their  use. 

(3)  iVucleo-albiimmiiria  and  muciiiuria. — 
We  have  already  mentioned  that  both  a  nucleo-albumin 
(or  a  substance  very  closely  resembling  one)  and  mucin 
occur  normally  in  the  urine,  and  it  is  probable  that  the 
so-called  "  mucus  '-  of  the  urine  consists  mainly  of 
the  former.  In  catarrhal  conditions  of  the  urinary 
passages,  however,   and   esj^ecially  of  the  bladder,  an 

*  Centralh.f.  d.  Med.  Wissenschaften,  No.  7,  1894. 

t  American  Journal  of  the  Medical  Sciences,  May,  1896. 


Proteids  in  the  Urine.  303 

excess  of  true  mucus  may  appear  in  the  urine,  and  to 
this  the  term  "iiiiiciiiiiria"  has  been  applied.  As 
long  as  the  urine  is  acid  mucin  is  insoluble  and  forms 
a  deposit  at  the  bottom  of  the  vessel.  Such  a  deposit 
may  be  distinguished  from  pus  by  the  absence  of  pus 
cells  on  microscopical  examination,  and  by  the  fact  that 
on  adding  to  it  some  caustic  potash  the  solution  is  not 
decidedly  ropy,  as  it  is  in  the  case  of  pus.  If  the 
urine  is  alkaline  the  mucin  goes  partially  or  entirely 
into  solution.  It  may  then  be  detected  by  adding  to 
the  urine  a  few  drops  of  acetic  acid.  A  white  cloud 
insoluble  in  excess  indicates  mucin.  This  often  suc- 
ceeds better  if  the  urine  be  previously  diluted  with 
its  own  bulk  of  water,  as  the  presence  of  a  large 
quantity  of  salts  tends  to  prevent  the  precipitation. 
Mucin  gives  no  precipitate  with  ferrocyanide  of  potash 
and  acetic  acid,  provided  the  former  be  added  first. 
AVe  have  already  said  that  micleo-albiiinimu'ia 
is  very  apt  to  be  mistaken  for  ordinary  albuminuria. 
The  reason  of  this  is-  that  nucleo-albumin  gives  most 
of  the  ordinary  albumin  reactions.  Thus  it  gives  a 
positive  result  with  Heller's  and  with  the  ferrocyanide 
test.  It  may  be  distinguished  by  the  fact  that  it  is  pre- 
cipitated on  the  addition  of  acetic  acid  or  on  saturation 
of  the  urine  with  sulphate  of  magnesium.  It  is  rather 
more  difficult  to  distinguish  it  from  mucin.  The  latter 
is  insoluble  in  excess  of  acetic  acid,  nucleo-albumin  is 
soluble  in  large  excess.  This  test,  however,  is  not 
always  quite  satisfactory.  Mucin  does  not  give  the 
ferrocyanide  reaction  if  the  acetic  acid  be  added  last ; 
nucleo-albumin  does.  Nucleo-albumin  gives  a  sharp 
ring  with  Heller's  test ;  mucin  only  a  diffuse  haze. 
Nucleo-albumin  yields,  as  a  rule,  no  reducing  substance 
on  boiling  with  mineral  acid,  and  its  ash  contains 
phosphorus;  mucin  yields  a  reducing  substance,  and  its 
ash  is  phosphorus-free.  The  significance  of  nucleo- 
albuminuria  has  not  yet  been  fully  made  out.     It  seems 


304  The  Urine. 

to  occur  not  unfrequently  in  febrile  diseases  or  in  con- 
ditions associated  with  a  destruction  of  the  secreting 
cells  of  the  kidney. 

"Fibrinuria"  has  already  been  described  (p.  273). 

II.— BLOOD   AND   ITS   DERIVATIVES. 

Blood  may  appear  in  the  urine  as  a  whole 
(hsematuria),  or  blood  pigment  may  appear  without 
corpuscles  (hsemoglobinuria).  These  two  conditions 
can  only  be  diflferentiated  by  examining  the  deposit 
for  blood  cells.  There  is  here  one  source  of  fallacy. 
In  alkaline  urines,  especially  if  they  have  stood  for 
some  time,  the  red  cells  are  apt  to  swell  up  and 
disappear.  The  urine  should,  therefore,  be  examined 
as  fresh  as  possible. 

If  a  urine  contains  only  a  small  amount  of 
blood  or  blood  pigment  it  has  a  peculiar  opaque 
appearance,  to  which  the  term  "smoky"  is  applied. 
Larger  quantities  of  blood  give  to  the  urine  a  red 
appearance  varying  in  intensity  with  the  amount  of 
blood  present.  The  blood  corpuscles  are  apt  to  settle 
to  the  bottom,  producing  a  flocculent  deposit,  which  is 
brown  or  red  according  to  the  amount  of  the  blood 
and  the  degree  of  its  alteration. 

The  following  tests  depend  upon  the  presence  of 
blood  pigment,  and  therefore  give  a  positive  reaction 
both  in  hfematuria  and  in  hsemoglobinuria. 

(1)  Heller's  test. — Place  2  inches  of  the  urine  in 
a  test  tube  and  render  it  strongly  alkaline  with 
caustic  soda.  Boil.  If  blood  pigment  is  present  the 
deposit  is  brownish-red  in  colour  while  the  super- 
natant fluid  is  bottle-green. 

The  precipitate  consists  of  earthy  phosphates 
which  have  carried  down  with  them  hsematin 
derived  from  the  blood  pigment,  and  are  therefore 
reddish  in  colour  instead  of  being  white  or  yellowish. 
If  the  urine  be  alkaline  a  few  drops  of  calcium  chloride 


Blood  in  the  Urine.  305 

solution  should  be  added  to  form  more  earthy 
phosphates.  If  the  \irine  be  very  dark,  as  it  may  be, 
{e.g.)  from  the  presence  of  bile,  the  supernatant  fluid 
should  be  decanted  off  the  precipitate  and  replaced  by 
water.  The  test  is  suifficiently  delicate  to  reveal  the 
presence  of  1  cc.  of  blood  in  1  litre  of  urine. 

Fallacies. — If  the  patient  is  taking  senna, 
santonin,  or  rhubarb  the  test  may  yield  a  positive 
result  even  although  no  blood  is  present.  If  the 
coloration  is  due  to  haemoglobin,  however,  the  pre- 
cipitate yields  the  spectrum  of  alkaline  hsematin 
(Fig.  63),  and  this  excludes  all  possibility  of  fallacy. 

(2)  Guaiac  test. — Take  1  inch  of  urine  in  a 
test  tube,  add  to  it  two  drops  of  tincture  of  guaiac. 
A  white  precipitate  forms,  owing  to  partial  precipi- 
tation of  guaiac  resin.  Now  add  1  inch  of  ozonic 
ether  without  shaking.  If  blood  pigment  is  present  a 
blue  colour  appears  at  the  junction  of  the  fluids. 

The  blue  colour  is  due  to  oxidation  of  the  guaiac 
by  oxygen  derived  from  the  ozonic  ether,  the  blood 
pigment  acting  as  the  carrier.  Ozonic  ether  is  a 
solution  of  peroxide  of  hydrogen  in  sulphuric  ether. 

Fallacies. — If  iodides  are  present  in  the  urine  a 
blue  colour  is  produced  on  applying  the  test.  It  is 
distinguished  from  that  due  to  blood,  (1)  by  the  fact 
that  it  appears  much  more  slowly,  (2)  by  its  appear- 
ing simultaneously  all  through  the  fluid,  not  at  the 
junction  of  the  ether  and  the  urine. 

Pus  gives  a  greenish-blue  colour  with  guaiac  alone. 
It  disappears  on  heating. 

The  presence  of  much  saliva  in  the  urine  {e.g.  from 
the  patient  spitting  into  it)  is  also  a  possible  source 
of  fallacy,^  as  it  gives  the  guaiac  test. 

]?Iethseiiiog:loI>iiiHrm. —  Methsemoglobin  may 
be  formed  from  htemoglobin  in  any  acid  urine  after  it 
has  stood  for  some  time.  Not  unfrequently,  how- 
ever, methsemoglobin  is  present  in  the  urine  when 
u 


3o6  The   Urine. 

passed.  It  lias  been  said  to  indicate  that  the 
haemorrhage  has  its  origin  in  the  kidney.  The  cha- 
racteristic smoky  tint  of  the  urine  in  hsematuria  of 
renal  origin  is  largely  due  to  methaemoglobin.  The 
pigment  present  in  "  paroxysmal  hsemoglobinuria " 
consists  largely  of  methsemoglobin.  Spectroscopic 
examination  is  the  only  satisfactory  test  for  methae- 
moglobin.  The  urine  if  very  dark  in  colour 
should  first  be  diluted,  and  it  should  always  be 
filtered.  It  should  then  be  examined  in  a  layer 
5  cm.  thick— a  small  flat  glass  bottle  does  well 
enough.  If  methsemogiobin  is  present  there  will 
be  a  band  visible  in  the  red,  in  addition  to  two 
bands  nearly  in  the  position  of  those  due  to  oxy haemo- 
globin (see  Fig.  63). 

Hsematoporphyriiiiiria.  —  Haematoporphyrin 
(iron-free  haematin)  occurs  normally  in  the  urine 
in  very  small  amount,  and  may  be  considerably 
increased  without  affecting  its  colour.  When  present 
in  large  quantities  the  urine  has  a  dark  port-wine 
colour.  Such  a  urine  does  not  give  the  guaiac  reaction. 
If  examined  with  the  spectroscope  in  a  thin  layer  it 
may  possibly  show  the  characteristic  spectrum  of 
so-called  alkaline  haematoporphyrin,  that  being  the 
form  met  with  even  in  acid  urines.  Often,  however, 
no  distinct  spectrum  can  be  obtained  on  direct 
examination  of  the  urine.  In  such  a  case  the 
pigment  can  be  extracted  by  shaking  up  the  urine 
with  a  little  amylic  alcohol  or  acetic  ether,  after  the 
addition  of  a  few  drops  of  acetic  acid.  The  extract 
so  obtained  shows  the  bands  of  alkaline  haemato- 
porphyrin, viz  :  4  bands,  one  at  the  junction  of  the 
red  and  yellow,  a  second  in  the  yellow,  a  third  in 
the  green,  and  a  fourth  (the  broadest)  between  the 
green  and  the  blue  (see  Fig.  63).  On  adding  a 
drop  or  two  of  hydrochloric  acid  the  bands  of  acid 
haematoporphyrin  are  obtained,  viz.  2  bands,  one  in 


Blood  in  the   Urine.  307 

the  orange  (narrow)  and  one  at  tlie  junction  of  the 
yellow  and  green  (broader).  The  latter  is  the 
characteristic  band  and  consists  really  of  two  halves, 
a  lighter  half  on  the  side  next  the  narrow  band  and  a 
very  dark  half  on  the  side  away  from  it. 

Hferaatoporphyrin  sometimes  appears  in  large 
amount  in  the  urine  of  patients  who  are  taking 
sulphonal,  but  much  more  commonly  in  females  than 
in  males.  It  is  a  sign  of  very  grave  signiticance,  as  such 
cases  often  terminate  fatally.  The  excretion  of  port- 
wine-coloured  urine  by  a  patient  who  is  taking 
sulphonal  is  always  an  indication  for  the  immediate 
stopping  of  the  drug  and  for  the  free  administration 
of  alkalies. 

Urine  which  contains  blood  or  haemoglobin  con- 
tains also,  of  course,  some  albumin,  and  it  is  often 
difficult  to  say  whether  the  blood  is  sufficient  to 
account  for  all  the  albumin  present  or  whether  true 
albuminuria  exists  as  well.  We  have  found  that  if 
human  blood  be  added  to  normal  urine  in  an  amount 
sufficient  to  produce  distinct  smokiness,  the  quantity 
of  albumin  amounts  to  merely  a  trace.  Even  when 
the  quantity  added  is  sufficient  to  render  the  urine 
distinctly  red,  the  amount  of  albumin  as  shown  by 
Esbach's  method  is  only  \  per  1,000. 

Ill— SUGARS    IN    THE    URINE. 

The  only  sugars  which  are  of  practical  importance 
in  the  examination  of  the  urine  are  glucose  and 
lactose.  It  is  possible  that  Isevulose  may  sometimes 
occur  along  with  glucose.  Cane  sugar  and  maltose 
may  conceivably  appear  in  the  urine  if  excessive 
quantities  of  either  be  ingested.  The  occurrence 
has  been  described  of  the  special  varieties  of  sugar 
known  as  the  pentoses,  but  these  are  only  very 
rarely  present,  and  are  not  yet  of  much  clinical 
importance. 


3o8  T^HE   Urine. 

Oliicose  ill  the  iiriuo. — Glucose  (dextrose  or 
grape  sugar),  CgH^.^Og,  is  by  far  the  commonest 
variety  of  sugar  met  with  in  the  urine.  The  con- 
dition is  spoken  of  generally  as  "glycosuria."  This 
must  be  distinguished  from  "  diabetes."  Diabetes — or, 
more  correctly,  diabetes  mellitus — is  a  disease  of  which 
glycosuria  is  the  chief  symptom,  but  every  patient 
with  glycosuria  has  not  necessarily  got  diabetes.  It 
has  long  been  dis})uted  whether  or  not  traces  of 
glucose  occur  in  normal  urine.  Recent  researches 
appear  to  have  finally  settled  the  question.  Traces 
of  glucose  do  occur  in  normal  urine,  but  not  in  an 
amount  capable  of  detection  by  the  reagents  usually 
employed.  If,  therefore,  glucose  be  detected  by  any 
of  the  tests  we  are  about  to  describe,  its  presence  may 
be  regarded  as  pathological. 

Tests  for  glucose  in  tlie  urine. — A  group  of 
these  tests  depends  upon  the  fact  that  glucose  can 
become  oxidised  at  the  expense  of  certain  metallic 
oxides,  this  oxidation  occurring  most  easily  at  a 
temperature  near  boiling,  and  in  the  presence  of  free 
caustic  alkali.  Copper  is  the  metal  usually  employed 
in  the  test.  If  one  takes  a  solution  of  caustic  soda 
and  adds  to  it  a  few  drops  of  a  very  dilute  solu- 
tion of  sulphate  of  copper,  a  blue  precipitate  forms. 
This  is  hydrated  cupric  oxide  (CuO-HoO).  If  now 
one  boils  the  blue  precipitate  it  becomes  black  from 
the  separation  of  cupric  oxide  (CuO).  In  the  presence 
of  certain  substances,  however — such,  for  example,  as 
a  tartrate^ — the  cupric  hydrate  formed  on  the  addition 
of  the  sulphate  goes  into  solution  instead  of  being 
precipitated.  A  deep  blue  fluid  then  results,  which 
remains  unaltered  on  boiling.  If  an  oxidisable  sub- 
stance such  as  glucose  is  present,  however,  the  blue 
cupric  hydrate  is  reduced  on  boiling  to  cuprous 
hydrate  (CuoO'HgO),  which  is  not  capable  of  being 
held  in  solution,  and  accordingly  appears  as  a  yellow 


Sc'G.-i/^s  i\  THE   Urine.  309 

precipitate,  or  it  may  be  further  dehydrated  to 
cuprous  oxide  (CuoO),  which  is  red.  Now,  ghicose 
is  not  merely  capable  of  reducing  cupric  hydrate,  but 
it  is  also  one  of  the  substances  which,  like  the  tar- 
trates, is  capable  of  holding  it  in  solution.  Hence, 
if  a  solution  of  glucose  be  rendered  alkaline  with 
caustic  soda,  and  a  few  drops  of  cupric  sulphate  solu- 
tion added,  the  cupric  hydrate  formed  is  dissolved 
and  a  blue  solution  results.  On  raising  this  to 
the  boiling  point  the  glucose  reduces  the  cupric 
hydrate,  and  yellow  cuprous  hydrate  or  red  cuprous 
oxide  is  precipitated. 

Such  is  a  brief  account  of  the  chemistry  of  the 
copper  test  for  sugar.  The  two  chief  methods  of 
applying  it  are  : — 

(1)  Trommer's  test. — Take  2  in.  of  the  urine  in 
a  test  tube,  add  -|-  of  its  volume  of  caustic  potash, 
and  then  drop  in  carefully  some  1  per  cent,  solution 
of  sulphate  of  copper,  shaking  after  each  addition. 
If  any  considerable  quantity  of  glucose  is  present  the 
cupric  hydrate  formed  is  at  once  dissolved,  and  a 
blue  solution  results.  Continue  to  add  sulphate  of 
copper  until  a  little  cupric  hydrate  remains  undis- 
solved. Boil  the  upper  part  of  the  fluid  and  it 
becomes  yellow  from  separation  of  cuprous  hydrate ; 
and  on  prolonged  boiling  this  becomes  red  (CuoO). 
If  more  cupric  hydrate  has  been  formed  than  the 
amount  of  sugar  present  is  capable  of  holding  in 
solution,  the  excess  yields  black  cupric  oxide  on  boil- 
ing, which  obscures  the  result.  Hence  the  advantage 
of  Fehlino-'s  reao-ent  in  which  solution  of  all  the 
cupric  hydrate  is  ensured  by  the  addition  of  a  tar- 
trate. The  formula  for  the  reasjent  will  be  found 
in  the  Appendix  (14). 

If  even  a  small  quantity  of  glucose  is  present, 
the  reduction  in  Trommer's  test  begins  before 
the   boiling  point  is  reached.      Glucose  is  the  only 


3 TO  The   Urine. 

substance  likely  to  be  found  in  the  urine  which  will 
do  this. 

(2)  Fehling's  test. — As  a  preliminary  to"  carry- 
ing out  the  test,  one  must  always  make  sure  that 
the  reagent  is  good.  This  is  necessitated  by  the  fact 
that  Fehling's  solution  alters  on  keeping,  with  the 
result  that  on  boiling  it  deposits  a  precipitate  of 
cuprous  oxide.  The  exact  nature  of  the  alteration 
is  not  fully  understood.  To  test  the  Fehling's  solu- 
tion add  to  it  an  equal  volume  of  water,  and  boil  for 
two  minutes.  If  the  solution  remains  clear,  it  is 
to  be  regarded  as  safe.  Should  a  precipitate  occur, 
a  little  more  caustic  soda  should  be  added  and  the 
liquid  filtered.  It  is  then  ready  for  use.  Add  to 
1  in.  of  Fehling  in  a  test  tube  a  few  drops  of  the 
urine  (freed  from  albumin),  and  boil.  If  any  con- 
siderable quantity  of  glucose  is  present,  a  yellow 
or  red  precipitate  will  appear.  Should  none  be 
evident,  add  as  much  urine  as  there  was  Fehling,  and 
boil  for  two  minutes.  Set  aside.  If  after  standing 
the  solution  still  remains  quite  clear,  there  cannot 
be  more  than  a  mere  trace  of  sugar  present.  "  If  the 
proportion  of  sugar,"  says  Allen,*  "  be  moderate- 
that  is,  under  0*8  per  cent. — the  precipitation  of  the 
yellow  or  red  cuprous  oxide  does  not  take  place 
immediately,  but  occurs  as  the  liquid  cools,  the  ap- 
pearance being  somewhat  peculiar.  The  liquid  first 
loses  its  transparency,  and  passes  from  a  clear  bluish- 
green  to  an  opaque  light  greenish  colour.  This  green 
milky  appearance  is  said  to  be  very  characteristic 
of  dextrose,  but  it  would  be  more  correct  to  say 
that  its  appearance  indicated  the  j^resence  of  some 
substance  interfering  with  the  normal  reaction  of 
sugar."  Uric  acid,  creatinin,  and  many  other  sub- 
stances may  act  as  such  interfering  agents.  Their 
presence  renders  the  indications  of  Fehling's  test 
*  "Chemistry  of  Urine,"  p.  61. 


SUGA/iS    IN    THE     UrINE.  3II 

uncertain  when  only  small  quantities  of  sugar  are 
present,  Allen  has  accordingly  proposed  the  follow- 
ing modification  of  Fehling's  test  by  taking  advantage 
of  the  fact  that  a  sliglitly  acid  solution  of  cupric 
acetate  will  precipitate  most  of  these  "  interfering  " 
substances  without  affecting  any  form  of  sugar.  He 
proceeds  as  follows  : — 

Heat  7-8  cc.  of  the  urine  to  boiling  in  a  test  tube, 
and,  without  removing  any  precipitate  of  albumin, 
add  5  cc.  of  the  cupric  sulphate  solution  used  in 
preparing  Fehling.  Partially  cool  the  liquid  and  add 
1-2  cc.  of  a  saturated  solution  of  sodium  acetate,  con- 
taining enough  acetic  acid  to  give  it  a  feebly  acid 
reaction.  Filter.  To  the  filtrate  add  5  cc.  of  the 
alkaline  tartrate  mixture  used  for  Fehling,  and  boil 
for  twenty  seconds.  If  more  than  0"2  per  cent,  sugar 
is  present,  cuprous  oxide  separates  before  the  boiling 
point  is  reached.  With  smaller  quantities  precipita- 
tion takes  jjlace  during  the  cooling  of  the  solution, 
which  becomes  greenish,  opaque,  and  suddenly  deposits 
cuprous  oxide  as  a  fine  yellow  precipitate. 

Certain  iirecaidions  and  fallacies  in  the  use  of 
Fehling's  test  hav^e  still  to  be  mentioned. 

In  the  first  place,  the  urine  must  be  free  from 
albumin.  If  necessary  add  a  drop  or  two  of  acetic 
acid  to  the  urine,  boil  and  filter.  Neutralise  the 
filtrate  with  a  little  calcium  carbonate. 

Fehling's  test  cannot  be  applied  to  strongly  am- 
moniacal  urine,  as  the  free  ammonia  would  prevent 
precipitation  of  cuprous  oxide.  In  that  case,  Pavy's 
modification  should  be  employed  (p.  315). 

If  the  amount  of  glucose  present  be  more  than 
is  required  for  reduction  of  all  the  cupric  oxide,  some 
of  it  is  apt  to  be  caramelised,  especially  on  prolonged 
boiling.  The  whole  liquid  and  precipitate  then  become 
of  a  dark  brownish  colour. 

The  fallacies  attendant  upon  the  use  of  Fehling's 


312  The   Urine. 

test  are  due  to  the  fact  that  other  substances  in  the 
urine  besides  glucose  can  reduce  cupric  oxide.  The 
chief  of  these  are  uric  acid,  creatinin  and  hippuric 
acid  among  the  normal  ingredients ;  of  the  abnormal 
constituents,  the  chief  are  lactose,  glycuronic  and 
glycosuric  acids,  and  the  products  of  certain  drugs — • 
e.g.  chloral,  chloroform,  glycerine,  benzoic  acid,  salicy- 
lates, carbolic  acid,  etc.  ;  "  alcapton "  urines  also 
reduce  Fehling.  If  the  patient  be  taking  no  drugs, 
and  if  the  urine  be  examined  by  Fehling's  method  as 
modified  by  Allen,  the  only  substances  likely  to  lead 
to  error  are  glycuronic  acid  and  lactose.  If  one  is 
still  in  doubt,  the  following  additional  tests  should 
be  employed  : — 

(3)  Picric  acid  test. — Take  1  in.  of  urine  in  a 
test  tube.  Add  \  in.  of  saturated  solution  of  picric 
acid  and  a  few  drops  of  caustic  potash  ;  heat.  If 
sugar  is  present,  the  solution  becomes  of  a  very  dark 
red  colour,  owing  to  the  reduction  of  the  picric  to 
picraiilic  acid. 

Fallacies. — (1)  Normal  urine  causes  some  darken- 
ing of  the  fluid  when  the  test  is  carried  out  as  above. 
This  is  owing  to  the  creatinin  which  it  contains.  The 
colour  is  not  nearly  so  dark  as  that  produced  by 
sugar,  and  the  solution  always  remains  transparent 
when  held  up  to  the  light.  (2)  If  the  picric  acid 
is  impure,  it  may  darken  spontaneously  when  heated 
with  caustic  potash.  It  is,  therefore,  well  to  test 
the  picric  acid  employed  before  using  it. 

(4)  Phenyl  hydrazine  test.  —  Place  in  a  test 
tube  \  in.  of  powdered  phenyl  hydrazine  hydro- 
chloride and  I  in.  of  powdered  acetate  of  soda,  and 
then  half  fill  the  test  tube  with  the  urine.  Boil  for 
two  minutes  without  shaking.  Set  aside  to  cool, 
and  examine  the  deposit  after  some  hours.  If  sugar 
is  present^  yellow  needle-shaped  crystals  (phenyl 
glucosazon)  will  be  found  arranged  in  stars  or  fans. 


Sugars  in  the   Urine.  313 

The  crystals  are  fairly  long.  Glycuronic  acid  and 
pentose  also  give  crystals,  but  are  very  rarely  present. 
The  crystals  yielded  by  lactose  are  also  almost 
identical  in  appearance  with  those  of  glucose.  The 
chief  value  of  the  test  is  a  negative  one.  If  no 
crystals  are  found,  sugar  is  certainly  absent. 

(5)  Fermentation  test. — This  is  really  the  only 
absolutely  certain  test  for  glucose,  that  being  the 
only  fermentable  substance  which  is  ever  found  in 
the  urine.  Neither  lactose  nor  glycuronic  acid — the 
two  substances  most  liable  to  be  mistaken  for  glucose 
— is  fermentable.  The  following  precautions  must 
be  observed  in  carrying  out  the  test : — (1)  The  urine 
must  be  acid.  Alkaline  urine  would  putrefy  ;  there- 
fore render  it  acid,  if  necessary,  by  adding  tartaric 
acid.  (2)  Boil  the  urine  for  ten  minutes,  so  as  to 
drive  off  any  air  it  may  contain.  Use  German  yeast. 
Shake  the  urine  up  with  a  small  piece  of  it,  so  as  to 
form  an  emulsion  free  from  lumps,  then  place 
the  urine  so  prepared  in  a  tube.  Special  fermenta- 
tion tubes  are  manufactured.  If  one  of  these  be  not 
obtainable,  an  ordinary  test  tube  inverted  in  a  bath  of 
mercury  will  do.  A  Doremus  (Soutliall's)  ureometer 
tube  does  extremely  well.  The  long  limb  of  it 
should  be  filled  with  the  urine  completely,  no  air 
bubbles  being  left.  Set  aside  the  tube  in  a  warm 
place,  and  examine  after  a  few  hours.  If  a  distinct 
bubble  has  appeared  at  the  top  of  the  tube,  the 
urine  is  fermentable,  and  contains  at  least  ~q  per 
cent,  glucose.  Care  must  be  taken  to  ascertain 
that  the  yeast  is  active.  It  should  be  tested  with  a 
dilute  solution  of  glucose.  It  is  also  well  to  have 
a  control  tube  full  of  normal  urine  to  which  yeast 
has  been  added,  as  the  yeast  itself  is  apt  to  give  off  a 
little  gas. 

If  these  precautions  be  observed,  the  test  is 
absolutely  trustworthy  and  extremely  delicate. 


314  The  Urine. 

Quantitative  estimation  of  sugar. 

(I)  Fehling's  iiiethod  consists  in  titrating  the 
urine  with  a  known  quantity  of  Fehhng's  solution 
at  boihng  temperature,  and  observing  when  all  the 
cupric  acid  has  been  reduced  to  cuprous  oxide,  as 
evidenced  by  the  discharge  of  all  the  blue  colour 
from  the  solution.  As  Fehling's  is  a  standard 
solution,  and  as  the  exact  quantity  of  glucose  re- 
quired for  the  complete  reduction  of  a  given  quantity 
of  it  is  definitely  known,  it  is  easy  to  estimate  the 
amount  of  glucose  present  from  the  quantity  of  urine 
used  up  in  the  titration.  One  proceeds  as  follows  : — 
If  ordinary  diabetic  urine  is  being  examined, 
it  should  be  diluted  to  the  extent  of  1  in  20  (5  cc.  of 
urine  to  95  cc.  of  water).  Fill  a  burette  with  it. 
Measure  10  cc.  of  Fehling's  solution  into  a  flask 
or  porcelain  basin,  and  add  50  cc.  of  water.  Boil  the 
mixture.  When  boiling,  run  in  the  urine,  stirring 
all  the  while.  It  is  a  little  difficult  to  be  sure  of 
the  exact  moment  when  all  the  Fehling's  solution 
has  been  reduced.  The  best  way  to  tell  is  to  remove 
the  flame  occasionally  and  tilt  the  basin,  so  that  one 
looks  through  a  layer  of  the  fluid  at  the  white  edge  of 
the  basin  instead  of  against  the  red  background  of 
cuprous  oxide  which  has  accumulated  at  the  bottom. 
Another  way  is  to  filter  a  few  drops  of  the  fluid 
through  a  small  filter  paper,  and  examine  the  filtrate 
against  a  white  surface.  If  there  be  any  tinge  of 
blue  left,  the  filtrate  must  be  returned  to  the  basin 
and  the  titration  continued.  When  complete  reduc- 
tion has  occurred,  read  ofl'  the  amount  of  urine  used. 
Calculation  :  10  cc.  Fehling  =  0-05  grm.  glucose. 
Suppose  10  cc.  of  the  diluted  urine  has  been  used, 
and  5,000  cc.  to  be  the  amount  of  urine  passed  in  24 
hours ;  then — 

a          '     ^A  X.               5,000  X  0-05        ^. 
Sugar  m  24  hours  =  — — =  25  grms. 


Sc/GARS    IN    THE     UrINE.  315 

but  the  urine  was  diluted  1  in  20, 
.-.  sugar  in  24  hours  =  25  x   20  =:  500  grms. 

To  get  the  result  in  English  measure,  remember 

that —     10  cc.  Fehling  =:  0*77  grain  sugar, 

28-395  =  cc.  in  1  oz. 

Therefore —  ounces  of  urine 

Grains  su^ar  in  24  hours 

.  »      =  T- X  0-77   X  28-3 

in  24  hours        number   or   cc. 

used, 

ounces  in  24  hours 

%.e.  =  ~ X  21-8. 

number  or  cc.  used 

The  result  must  be  multiplied  according  to  the 
degree  of  dilution. 

(2)  Pavy^s  method  is  much  more  convenient  for 
clinical  purposes.  It  differs  from  that  of  Fehling  in 
this — that  a  quantity  of  strong  ammonia  is  added 
to  the  alkaline  cupric  tartrate  solution.  Ammonia 
is  able  to  dissolve  cuprous  oxide,  the  solution  being 
colourless.  Hence  when  the  solution  is  titrated  at 
the  boiling  point  with  a  solution  containing  glucose, 
the  mixture  gradually  fades  until  every  trace  of  blue 
has  gone,  and  one  is  not  confused  by  the  throwing 
down  of  a  red  precipitate.  Pa^-j^^'s  solution  has  also 
the  advantage  of  keeping  indefinitely,  and  of  being 
possessed  of  an  originally  deeper  colour.  The  method 
of  preparing  it  will  be  found  in  the  Appendix  (15). 

Method. — Fill  a  burette  with  diluted  urine  as 
before.  The  outflow  from  the  burette  should  be 
regulated  by  a  stopcock  or  screw.  The  end  of  the 
burette  is  connected  with  a  tube  passing  through  the 
stopper  of  a  150  cc.  flask.  Another  hole  in  the 
stopper  allows  the  passage  of  an  exit  tube  for  the 
escape  of  the  fumes  of  ammonia  (Fig.  84).  Place  in 
the  flask  10  cc.  of  the  solution,  diluted  with  20  cc. 
water.  When  the  solution  is  boiling,  run  in  the  urine. 
It  should  be  run  in  at  the  rate  of  60-100  drops  per 


3i6 


The   Urine. 


minute.  Not  too  fast,  or  the  limit  of  reduction  may 
be  overstepped,  and  not  too  slowly,  or  all  the  ammonia 
may  be  driven   off  and   some   cuprous  oxide  thrown 


83. — Pavy's  Apparatus. 


down.     When   the   blue   colour   has   entirely   faded, 
take  a  reading  of  the  burette. 

The  calculation  is  performed  in  the  same  way  as 
for  Fehling's  method,  but  it  must  be  remembered 
that  10  cc.  of  Pavy's  solution  is  only  =  0-005  grm. 
i.e.  it  is 


ten  times  less  strong  than  Fehling's. 


glucose 

The  following  table  saves  the  trouble  of  calculation 


Sl/gaj?s  in  the  Urine. 


317 


TabJc  shmvinct  the  Amount  of  Siipar  expressed  in  Parts  {hy 
weight)  prr  1,000  (hii  volume),  e or re.^ ponding  with  cc,  in 
lOths,  required  to  Decolorise  10  Cf.  of  the  Animoniatcd  Cupric 
Test. 


cc  to  de- 

Parts  per 

cc.  to  de- 

Parts per 

cc.  to  de- 

Parts per 

coloris'e. 

1,000. 

colorise. 

1,000. 

colorise. 

] ,000. 

10 

5-000 

5-7 

•877 

10-4 

•480 

•1 

4-545 

-8 

•862 

•5 

•476 

•2 

4-166 

■9 

-847 

'6 

•471 

•3 

3  846 

6-0 

-833 

•7 

•467 

•4 

3-571 

-I 

-SI9 

•s 

•462 

"5 

3-333 

••"> 

-806 

•9 

•458 

■<■( 

3-1-25 

-3 

•793 

WO 

-454 

'  1 

2-041 

■4 

-7S1 

-1 

•4.'i0 

■s 

2-777 

-5 

769 

-2 

•446 

•9 

2-632 

-6 

-757 

!             -3 

-442 

2  0 

2-500 

-7 

•746 

•4 

•438 

•1 

2-380 

-8 

•735 

•5 

•434 

"1 

2-272 

•9 

•724 

•6 

•431 

•3 

2-173 

7-0 

•714 

•7 

•427 

•4 

2-083 

-1 

•704 

•8 

•423 

•5 

2-000 

•2 

•694 

•9 

•420 

•6 

1-923 

-3 

•684 

12^0 

•416 

•7 

1-851 

-4 

•675 

•1 

•413 

•8 

1-785 

-5 

•666 

•2 

•409 

•9 

1-724 

•6 

•657 

•3 

•406 

3-0 

1-G66 

•7 

•649 

■4 

•403 

•1 

1-612 

•8 

•640 

•5 

•400 

•2 

1-562 

-9 

•632 

•6 

•396 

•3 

1.515 

8-0 

•625 

•7 

•393 

•4 

1-470 

-1 

•617 

•8 

•390 

■5 

1-403 

-2 

•609 

•9 

•387 

•6 

1-388 

•3 

•602 

13^0 

•384 

■7 

1-351 

•4 

•595 

-1 

•381 

•s 

1-316 

•5 

•588 

•2 

•378 

•9 

1-281 

•6 

•581 

•3 

•375 

4-0 

1-250 

-( 

•574 

'             '4 

•373 

•1 

1-219         j 

-8 

•568 

1              •o 

•370 

•2 

1-190 

-9 

•561 

•6 

•367 

■3 

1-162         1 

9-0 

•555 

•  ( 

•364 

•4 

1-136 

-1 

•549 

•8 

•362 

•5 

1-111 

-2 

•543 

•9 

•359 

•tj 

1-086 

•3 

•537 

14-0 

•357 

•7 

1063 

•4 

•531 

•1 

•354 

•8 

1-041 

-5 

•526 

•2 

•352 

•0 

1-020 

•6 

•520 

•3 

•349 

50 

1-000 

-( 

•515 

•4 

•347 

•1 

•980 

•8 

•510 

•5 

•344 

"2 

•961 

•9 

-505 

•6 

•342 

•3 

-943 

10-0 

-500 

•7 

•340 

•4 

-925 

■1 

-495 

■8 

•337 

•5 

•909 

•2 

-490 

•9 

•335 

•6 

■    -892 

•3 

-485 

15  •© 

•338 

3i8  The   Urine. 

It  gives  the  sugar  in  grammes  per  1,000  cc.  The 
same  table  may  be  used  for  Fehliug's  method  (pro- 
vided that  10  cc.  of  Fehling  has  been  taken),  the 
number  of  parts  per  1,000  being  always  multiplied 
by  10,  to  allow  for  the  greater  strength  of  Fehling's. 
solution;  e.g.  if  10  cc.  diluted  urine  is  used  in 
Pavy's  method,  reference  to  the  table  shows  that  this 
means  0*5  grm.  sugar  per  1,000  cc. ;  by  Fehling's 
method,  it  would  be  equivalent  to  5  grm.  per  1,000  cc. 
In  each  case  the  result  must  be  multiplied  by  20  if 
the  urine  has  been  diluted  1  in  20,  and  if  it  be  desired 
to  express  the  result  in  grains  per  ounce  the  amount 
per  1,000  cc.  should  be  multiplied  by  04 375. 

In  both  methods  the  urine  must  be  freed  from 
albumin  (if  necessary)  by  adding  two  drops  of  acetic 
acid,  boiling,  neutralising  with  calcium  carbonate, 
filtering  and  making  up  to  the  original  volume  with 
water. 

In  an  ordinary  case  of  diabetes,  3  litres  or  so. 
(about  5|  pints)  of  urine  will  be  passed  daily,  con- 
taining on  an  average  100  grms.  of  glucose  (3-4 
per  cent.). 

Lactosiiritt. 

Lactose  is  sometimes  found  in  appreciable  quantity 
in  the  urine  of  women  who  are  nursing.  It  reduces 
Fehling's  solution,  and  gives  yellow  crystals  of  phenyl 
lactosazon  with  the  phenyl  hydrazin  test,  which  are 
broader  than  those  yielded  by  glucose,  but  it  gives 
no  reaction  with  the  fermentation  test.  It  may  be 
estimated  by  titration  with  Fehling's  solution^  it 
being  remembered  that  the  reducing  power  of  lactose 
is  to  that  of  glucose  as  10  is. to  7  ;  i.e.\i  7  parts  of 
glucose  reduce  a  given  quantity  of  Fehling,  it  will 
require  10  of  lactose  to  eflect  the  same  result. 

Pentosuria. — This  is  a  condition  only  recently 
described.  It  consists  in  the  presence  in  the  urine  of 
pentoses,  i.e.  carbohydrates  containing  only  5  atoms 


Bile  in  the  Urine.  319 

of  carbon.  They  have  the  general  formulre,  C-Hj^jO^. 
The  pentoses  do  not  exist  free  in  nature,  but  can 
be  obtained  easily  by  hydrolytic  decomposition  of 
complex  carbohydrates  belonging  to  the  gum  class, 
present  in  many  fruits  {e.g.  cherries).  They  are  dis- 
tinguished from  the  hexoses,  such  as  glucose  in  not 
furnishing  Isevulinic  acid  in  decomposition  with  sul- 
phuric acid  or  HCl.  With  phloroglucin  and  HCl 
they  give  a  cherry  red  reaction. 

They  furnish  osazones,  are  not  fermentable  and, 
on  distillation  with  HCl,  furfurol  is  given  off. 

They  are  optically  active,  and  reduce  cupric  oxide. 
They  only  occur  very  rarely  in  the  urine,  and  their 
pathological  significance  is  unknown. 

IV.— BILE    IN    THE    URINE. 

Both  bile  pigment  and  bile  acids  may  be  present. 
Usually  they  occur  together,  but  the  pigment  much 
more  abundantly  than  the  acids.  The  usual  cause  of 
the  entrance  of  the  bile  constituents  into  the  urine  is 
some  obstruction  in  the  bile -passages.  It  was  for- 
merly believed  that  bile  pigment  could  be  formed  in 
the  blood  owing  to  a  destruction  of  the  normal  blood 
pigment,  and  thence  find  its  way  into  the  urine, 
constituting  the  so-called  "haematogenous"  jaundice. 
This  is  now  known  to  be  an  error.  It  is  also  very 
doubtful  whether  traces  of  the  bile  acids  are  really 
always  present  in  the  urine,  as  is  the  belief  of  some. 
As  long  as  the  urine  is  fresh,  bilirubin  is  the  form  of 
bile  pigment  always  found  in  it.  After  it  has  stood 
for  some  time,  biliverdin  is  apt  to  be  formed  as  the 
result  of  oxidation. 

Urine  which  contains  bile  is  greenish  or  brownish- 
yellow  in  colour,  and  somewhat  more  viscid  than 
normal,  so  that  the  froth  which  forms  on  the  top 
after  shaking  is  unusually  permanent.  Salol  urine 
may  closely  resemble  urine  which  contains  bile,  but 


32 o  The  Urine. 

the  froth  in  the  latter  case  is  also  greenish ;  in  salol 
urine  it  is  not. 

Tests  for  bile  ptg^inent. 

GmelinHs  test. — Place  some  of  the  urine  in  a 
conical  glass,  and  run  a  little  impure  nitric  acid  down 
the  side  so  as  to  form  a  layer  at  the  bottom.  Oxi- 
dation of  the  bile  pigment  occurs,  the  most  highly 
oxidised  product  (choletelin)  forming  a  yellowish  red 
ring  nearest  the  acid.  Above  this  is  a  reddish  ring, 
then  violet  (bilicyanin),  and  highest  of  all,  green  (bili- 
verdin).  Of  these  rings  the  green  is  alone  character- 
istic of  bile,  all  the  others  may  be  yielded  by  urinary 
indigogens.  The  test,  as  thus  carried  out,  is  not 
very  sensitive,  and  may  fail  even  when  5  per  cent,  of 
bile  is  present.  The  sensitiveness  of  the  reaction  can 
be  increased  by  repeatedly  filtering  the  urine  through 
an  ordinary  filter  paper.  The  latter  becomes  im- 
pregnated with  the  bile  pigment,  and  if  a  drop  of 
impure  nitric  acid  be  placed  upon  it  a  play  of  colours 
can  easily  be  seen. 

The  following  modification  of  it  is  much  more 
delicate  still,  and  should  always  be  employed  in 
doubtful  cases.  It  will  reveal  the  presence  of  0*2 
per  cent,  of  bile. 

To  50  cc.  urine  add  5  cc.  of  10  per  cent,  barium 
chloride  solution  and  5  cc.  chloroform.  Shake  for 
several  minutes.  Set  aside  for  ten  minutes. 
The  chloroform  and  precipitate  of  phosphates 
fall  down,  carrying  with  them  any  bile  pigment. 
If  there  is  still  any  of  the  precipitate  sus- 
pended, move  the  jar  gently  to  and  fro  for  a  little, 
when  it  will  settle  down.  Now  draw  off  the  chloro- 
form and  precipitate  with  a  pipette  ;  if  some  urine  is 
removed  at  the  same  time,  no  matter.  Place  in  a  flat 
dish,  and  set  the  latter  over  a  basin  of  hot  water  till  all 
the  chloroform  has  evaporated.  Allow  to  cool,  and 
pour  off  any  fluid  from  the  precipitate.     The  latter 


Bile.  321 

will  he  yellowish.  Place  impure  nitric  acid  in  drops 
here  and  there  on  the  surface  of  the  precipitate.  If 
bile  pigment  is  present,  a  play  of  colours  appears 
round  each  drop. 

Tests  for  bile  sicids. 

(1)  rettenkofer^s  Test. — Place  some  of  the  urine 
in  a  conical  glass.  Add  three  drops  of  syrup  of 
cane  sugar,  and  mix.  Pour  strong  sulphuric  acid 
down  the  side  so  as  to  form  a  layer  at  the  bottom. 
Then  shake  gently,  and  slowly  add  more  sulphuric 
acid.  If  bile  acids  are  present  a  purplish  red  colour 
appears.  This  is  often  most  easily  to  be  detected  in 
the  froth  which  forms  on  the  top  of  the  liquid  on 
shaking.  The  froth  acquires  a  pink  tinge  if  bile 
acids  are  present.  The  test  depends  on  the  formation 
of  f urfuraldehyde  from  the  sugar  and  acid ;  this 
unites  wdth  the  cholic  acid  of  bile  to  form  a  purplish 
compound.  The  urine  must  be  free  from  albumin  in 
Pettenkofer's  test. 

The  above  test  very  rarely  succeeds  well  in 
urine.  The  followinoj  delicate  test  has  been 
proposed  by  Oliver  as  a  substitute.  It  depends 
upon  the  power  of  bile  acids  to  precipitate  peptone 
in  acid  solution.  The  peptone  solution  is  pre- 
pared as  in  the  Appendix  (16).  Proceed  as 
follows  : — 

(2)  Oliver's  Test. — Filter  the  urine  until  quite 
clear,  acidify  it  if  necessary,  and  dilute  it  till  the 
specific  gravity  is  less  than  1,008.  Take  60  minims 
of  the  solution  in  a  test  tube  and  add  to  it  20 
minims  of  the  urine.  If  bile  acids  are  present  a 
decided  milkiness  appears  at  once,  and  is  dense  in 
proportion  to  the  amount  of  acids.  It  may  dis- 
appear on  agitation,  but  reappears  on  adding  more 
of  the  solution.  The  test  is  extremely  delicate, 
and  nothing  as  yet  found  in  the  urine  interferes 
with  it. 


32  2  The  Urine. 

V.^PUS   IN   THE   URINE  (PYURIA). 

The  naked-eye  characters  of  a  urine  which  con- 
tains pus  have  already  been  described  (p.  276).  On 
chemical  examination  such  a  urine  is,  of  course, 
always  albuminous.  It  is  often  difficult  to  decide, 
just  as  it  is  in  hsematuria,  whether  all  the  albumin 
is  accounted  for  by  the  pus  alone  or  whether 
there  is  true  albuminuria  in  addition.  Reinecke 
has  proposed  the  following  method  for  enabling 
one  to  form  a  conclusion  in  this  matter.  He  shakes 
up  the  urine  of  twenty-four  hours  thoroughly,  so 
as  to  diffuse  the  pus  evenly  through  it.  He  then 
counts  the  pus  cells  present  by  means  of  a  hsemo- 
cytometer,  just  as  in  the  method  for  estimating 
the  red  blood  corpuscles  in  the  blood,  only  without 
previous  dilution.  He  finds  that  100,000  pus  cells  per 
cubic  millimetre  should  correspond  to  1  per  cent,  of 
albumin  (Esbach).  If  there  be  more  albumin  than 
this  with  that  number  of  corpuscles,  then  albuminuria 
is  present  in  addition  to  pyuria.  Obviously,  the 
method  can  only  afford  approximate  indications.  More- 
over, it  is  inapplicable  if  the  urine  be  ammoniacal, 
or  if  it  contains  much  mucus.  It  should  be  added 
that  if  the  number  of  pus  cells  exceeds  3,000  per 
cubic  millimetre,  the  urine  should  be  diluted  with 
1  per  cent,  salt  solution  prior  to  counting. 

Tests  for  pus. — As  already  mentioned,  urines 
which  contain  pus  give  a  green  colour  on  the  addition 
of  guaiac,  which,  however,  disappears  upon  heating. 

If  liquor  potasses  be  added  to  the  deposit  of  pus, 
a  ropy,  gelatinous  mass  results.  For  the  micro- 
scopical recognition  of  pus  in  the  urine,  see  p.  338. 

Some  Rarer  Abnormal  Constituents  of  Urine, 

1.  Urinary  JiidJg'Og:ens. — We  have  seen  (p. 
283)  that  indol  is  excreted  in  the  urine  in  the  form  of 
potassium  indoxyl  sulphate — the  so-called  *'  indican." 


Indigogens.  323 

Small  quantities  of  potassium  skatoxyl  sulj)liate, 
derived  from  skatol,  are  also  to  be  found  in  human 
urine.  On  oxidation  these  compounds  yield  coloured 
substances,  indigo  blue  and  indigo  red.  Hence  they 
are  spoken  of  as  urinary  indigogens.  In  order  to 
detect  their  presence  one  oxidises  them  in  one  of  the 
following  ways  : — 

(1)  Remove  albumin,  if  present,  by  boiling.  Add 
to  some  of  the  urine  in  a  test  tube  an  equal  quantity 
of  hydrochloric  and  a  few  drops  of  nitric  acid,  and 
boil.  Cool  and  shake  up  with  a  little  chloroform. 
The  chloroform  dissolves  out  the  products  of  oxidation 
and  becomes  of  a  violet  tint  from  the  mixture  of 
indigo  blue  and  indigo  red,  if  excess  of  indigogens  is 
present.  The  presence  of  iodides  in  the  urine  must 
be  excluded  before  applying  this  test. 

(2)  Remove  albumin  and  add  hydrochloric  acid, 
as  above.  Then  drop  in  slowly  a  freshly  prepared 
dilute  solution  of  bleaching  powder  (1  in  20),  shaking 
all  the  time  till  the  blue  colour  ceases  to  become 
deeper.  The  indigo  blue  may  then  be  dissolved  out 
with  chloroform  as  above.  The  development  of  the 
blue  colour  does  not  proceed  very  rapidly,  and  one 
must  be  careful  not  to  add  too  much  bleaching  powder, 
or  oxidation  will  proceed  too  far,  colourless  compounds 
resulting. 

Traces  of  the  indigogens  are  normally  present  in 
the  urine.  The  reddish  yellow  transparent  ring  which 
appears  above  a  layer  of  nitric  acid  when  the  latter 
is  added  to  the  urine  is  due  to  their  partial  oxidation. 
They  are  increased  in  all  conditions  associated  with 
excessive  putrefaction.  Hence  they  are  much  in- 
creased whenever  the  intestinal  contents  are  unduly 
retained — e.g.  in  chronic  constipation  and  intestinal 
obstruction.     They  are  also  increased  in  some  fevers. 

2.  Acetone. — Hydroxybutyric  acid,  aceto-acetic 
acid,    and    acetone    may     all     occur    in    the    urine. 


324  The  Urine. 

The    relationship    between    the    three    may    be    seen 
from  the  following  formulae  : — 

i3-Hydroxy butyric  acid  =  CH3  CH(OH)OHoCOOH. 
Aceto-acetic   acid       r=  CH3  CO,  CH.COOH, 
Acetone  ...  =  CH3,  CO,  CH.. 

/3-Hydroxybutyric  acid  is  formed  first,  probably 
by  destruction  of  proteids ;  it  then  becomes  oxidised, 
yielding  aceto-acetic  acid. 

CH3CH(OH)CHoCOOH  +  0  =  CHgCOCH^ 

COOH  +  H3O. 
The  aceto-acetic  acid  is  very  easily  decomposed 
into  acetone  and  CO3. 

OHgCOCHgCOOH  =  CH3COCH3  +  COo 

Only  aceto-acetic  acid  and  acetone  require  to  be 
detected  in  the  urine.  Hydroxy  butyric  acid  always 
occurs  along  with  the  first  of  these. 

Test  for  aceto-acetic  acid. — The  urine  must  be  fresh 
and  unboiled,  as  the  acid  readily  decomposes.  Take 
some  urine  in  a  test  tube,  drop  in  a  solution  of 
perchloride  of  iron,  diluted  until  it  is  of  a  pale  sherry 
colour,  as  long  as  a  precipitate  of  phosphate  of  iron 
falls.  Filter,  and  add  to  the  filtrate  another  drop  or 
two  of  the  iron  solution.  The  solution  becomes  claret 
coloured  if  aceto-acetic  acid  is  present.  On  boiling 
the  urine  the  colour  disappears.  Antipyrin,  salicylates, 
carbolic  acid,  and  some  other  drugs  give  a  similar 
colour  with  perchloride  of  iron,  but  it  is  not  affected 
by  heat. 

Test  for  acetone. — Urine  containing  acetone  has 
a  peculiar  fruity  odour.  It  reduces  Fehling's  solution. 
The  best  test  for  its  presence  is  based  upon  its  ready 
conversion  into  iodoform  : — 

CgHfiO  +  4K0H  +  31,  =  SKI  +  KC.HgOg 
+  OHI3  (Iodoform)  +  3  H2  O. 

To  1  in.  of  the  urine  add  five  drops  of  10  per  cent. 


Glycuronic  Acid.  325 

caustic  soda  or  potasli.  Heat  gently.  Then  drop  in 
a  saturated  solution  of  iodine  in  potassium  iodide  until 
the  liquid  has  a  yellowish  brown  colour.  Then  add  a 
little  more  caustic  potash  or  soda.  Iodoform  appears 
as  a  yellowish  turbidity,  which  settles  down  into  a 
crystalline  precipitate.  It  may  be  recognised  by  its 
odour.  Under  the  microscope  it  consists  of  hexagonal 
plates  often  gathered  into  stars. 

If  only  traces  of  acetone  are  present,  it  is  better  to 
distil  the  urine  after  the  addition  of  a  little  phosphoric 
acid  and  test  the  distillate  as  above. 

Acetone  and  the  substances  from  which  it  is  derived 
are  especially  apt  to  appear  in  the  urine  in  cases  of 
diabetes,  and  are  to  be  regarded  as  of  grave  import, 
their  appearance  being  often  followed  or  accompanied 
by  the  development  of  coma.  They  are  also  found  in 
some  fevers. 

3.  Olyciiroiiic  acid. — (CgH^^QOy)  is  probably 
derived  in  the  body  from  dextrose.  Mere  traces  of  it 
exist  in  combination  in  normal  urine.  It  is  very  prone 
to  form  ethereal  or  glucosidal  compounds  if  suitable 
substances  are  introduced  into  the  circulation.  Hence 
it  appears  in  the  urine  in  considerable  quantity,  in 
paired  combination  with  aromatic  substances,  etc., 
after  the  administration  of  such  drugs  as  chloral, 
benzoic  acid,  chloroform,  morphia,  etc.  This  circum- 
stance gave  rise  to  the  old  belief  that  such  drugs 
produce  glycosuria ;  in  reality  the  substance  which 
is  excreted  after  their  use  is  glycuronic  acid,  not 
glucose. 

Occasionally  glycuronic  acid  occurs  spontaneously 
in  the  urine.  It  is  then  very  apt  to  be  mistaken  for 
glucose.  The  error  is  a  serious  one,  for  the  patho- 
logical significance  of  glycuronic  acid  in  the  urine  is 
much  less  grave  than  that  of  glucose,  Glycuronic 
acid  reduces  Fehling's  solution,  and  gives  a  yellow 
crystalline  precipitate  with  the  pheny Ih^  drazin  test. 


326  The  Urine. 

It    can    be    best    distinguished    from    glucose  in  the 
following  ways  : — 

(1)  It  does  not  ferment  with  yeast. 

(2)  Dissolve  some  jpure  phloroglucin  by  the  aid 
of  heat  in  5  cc.  of  fuming  hydrochloric  acid  so  that  a 
slight  excess  of  the  substance  remains  undissolved. 
Cool  and  divide  into  two  equal  portions.  To  one  add 
^  cc.  of  normal  urine  ;  to  the  other  a  similar  quantity 
of  the  urine  under  examination  after  decolorising 
both  with  animal  charcoal.  Place  both  in  a  beaker 
of  boiling  water.  In  a  few  minutes  the  urine  which 
contains  glycuronic  acid  will  show  a  red  scum  from 
which  a  bright  red  colour  spreads  throughout  it.  The 
normal  urine  remains  unaltered. 

4.  Cystin  (C3HgNS02)3  is  sometimes  found  as 
a  deposit  in  acid  urines.  It  is  recognised  by  its 
characteristic  crystals  {see  Fig.  88).  It  is  soluble  in 
alkalies  ;  hence  the  deposit  disappears  when  the  urine 
putrefies,  an  odour  of  sulphuretted  hydrogen  being 
evolved.  Its  origin  in  the  body  is  unknown.  Its 
presence  in  the  urine  is  not  of  much  pathological 
importance  except  from  its  tendency  to  form  calculi. 
Cystinuria  is  a  hereditary  disease  running  in  some 
apparently  healthy  families, 

VI.— EHRLICH'S   DIAZO    REACTION   IN 
URINE. 

We  shall  first  describe  this  test,  and  then  state  its 
significance.  The  reaction  depends  upon  the  fact  that 
if  sulphanilic  acid  (amido-sulpho-benzol)  be  acted  upon 
by  nitrous  acid,  diazo-sulpho-benzol  is  formed,  which 
unites  with  certain  aromatic  compounds  occasionally 
present  in  the  urine  to  form  aniline  colours.  Two 
solutions  are  necessary  :  (A)  A  saturated  solution  of 
sulphanilic  acid  in  5  per  cent,  hydrochloric  acid  ; 
(B)  a  \  per  cent,  solution  of  sodium  nitrite.  Both 
sojutioiis  should  be  as  fresh  as  possible, 


Drugs  in  the  Urine.  327 

Add  to  some  urine  in  a  test  tube  an  equal  quantity 
of  A  ;  then  add  three  drops  of  B,  and  shake  till  a  froth 
forms.  Render  alkaline  with  ammonia.  If  the  liquid 
becomes  of  a  port  wine  colour  while  the  froth  is  also 
red,  the  reaction  is  positive.  The  test  has  the  following 
significance  : — 

(1)  If  the  urine  of  a  supposed  typhoid  in  the 
second  or  third  week  fails  to  give  the  reaction,  the 
diagnosis  is  probably  wrong.  In  very  mild  cases, 
however,  the  reaction  may  be  absent. 

(2)  The  reaction  is  present  in  measles,  but  not 
in  German  measles  (rotheln).  It  is  thus  of  value 
in  distinguishing  between  the  two. 

(3)  It  is  very  constantly  present  in  tubercular 
disease  which  is  advancing  rapidly. 

VII.— DRUGS   IN   THE   URINE. 

Aiitipyrin. — After  its  use  the  urine  may  be  red 
and  dichroic,  leading  to  the  suspicion  that  blood 
is  present.  On  adding  a  little  dilute  perchloride  of 
iron  a  purplish  red  colour  develops,  which  persists 
on  boiling.  Urines  containing  antipyrin  produce  a 
partial  reduction  of  Fehling's  solution  on  boiling. 

Carbolic  acid  (see  also  section  on  Colour  of 
Urine,  p.  269). — The  best  test  for  it  is  to  add  a  little 
bromine  water.  The  appearance  of  a  whitish  precipitate 
(tribromophenol)  indicates  the  presence  of  phenol. 

Ciiloral,  cliloroform,  etc.,  lead  to  the  appear- 
ance of  glycuronic  acid  (p.  325). 

Bromides. — Add  a  little  hydrochloric  acid  and 
a  few  drops  of  a  weak  solution  of  bleaching  powder. 
Shake  with  chloroform,  and  the  latter  becomes 
brownish  i-ed  from  the  solution  of  the  free  bromine. 

Iodides. — Acidify  the  urine  with  a  little  pure 
nitric  acid,  and  shake  up  with  chloroform.  The  latter 
becomes  of  a  rose-red  colour. 

Iron. — Add  a  few  drops  of  nitric  acid.    Boil,  cool, 


328 


The   Urine. 


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Microscopical  Exam  in  a  tion. 


329 


and  add  a  little  10  per  cent,  ferrocyanide  of  potash. 

A  precipitate  of  Prussian  blue  forms  if  iron  is  present. 

Rhubarb  and  isaiitoiiiii  have  been  referred  to 

under  tJie  colour  of  the  urine  (p.  271). 

Salicylates  and  salol  appear  in  the  urine  as 
salicyluric  acid.  Such  a  urine  gives  a  bluish  violet 
colour  on  the  addition  of  a  little  perchloride  of  iron  ; 
it  also  partially  reduces  Fehling's  solution. 

Taiiitiu  gives  a  bluish  black  colour  with  per- 
chloride of  iron. 

SEOTIO^N"    III. 

MICROSCOPICAL    EXAMINATION    OF 
URINARY    DEPOSITS. 

1. — Unorgaulsecl  deposits. — The  first  group 
of  urinary  deposits  includes  the  various  salts  and 
crystalline  substances  that  are  found  in  urine,  either 
when  freshly  voided,  or  more  often  when  it  has  stood 


^F^  l&lr  '&^^^^  ^t 

^'^A^  ^^^'  '§kM^  yr 


# 


-«L> 


Fig.  84. — Deposit  in  acid  urine. 


for  some  time.       The  following   occur   in   acid  urine 
(Fig.  84). 

(1)  Uric  acid. — This  appears  under  a  variety  of 
foims,  and,  unless  the  urine  is  almost  devoid  of 
colouring  matter,  assumes  a  reddish  brown  colour  in 
consequence  of  its  absorbing  a  considerable  amount 
of    i)igment.       To    the    naked     eye    the    appearance 


330 


The  Urine. 


resembles  that  of  a  shower  of  grains  of  cayenne 
pepper  collected  at  the  bottom  of  the  specimen. 
Under  the  microscope  the  crystals  are  either  rhombic 
prisms  or  some  modification  of  that  form.  Often  the 
more  obtuse  angles  are  rounded   off  and   the  edges 


Fig.  85. — Uric  acid.    (Finlayson  after  Funlce.) 

continued  in  curved  lines,  so  that  pointed  oval  shapes 
result.  Numerous  crystals  may  be  joined  together  to 
produce  rosettes  and  other  composite  forms.  Some 
of  the  more  common  are  represented  in  the  accom- 
panying figure  (Fig.  85). 

(2)  Urate  of  soda,  occurs  rather  frequently  in 
the  urine  of  recently  born  infants,  when  it  produces 
a  yellow  stain  on  the  napkin.  In  adults  it  is  found 
very  seldom.  The  appearance  presented  under  the 
microscope  is  that  of  spheres,  either  solitary  or  in 
clusters,  having  a  more  or  less  crystalline  structure, 
and  possessing  numerous  spines  radiating  from  their 
surface  (Fig.  86). 


Microscopical  Examination. 


331 


(3)  Amorphous  urates. — These  are  quadri- 
urates  of  potassium,  sodium,  and  ammonium.  Tliey 
have  a  considerable  affinity  for  the  urinary  pigments, 
and  hence  are  generally 
more  or  less  pink  or  brick- 
coloured.  In  very  pale 
urines  they  are  colourless, 
and  resemble  rather  closely 
a  deposit  of  phosphates. 
Microscopically  they  con- 
sist of  small  granular  par- 
ticles, arranged  in  moss- 
like clumps.  On  heating 
a  urine  from  which  they 
have  separated  out,  they 
will  be  found  to  re- 
dissolve   before   the   boiling  point  has   been   reached. 

Uric  acid  and  urate  of  soda  can  be  preserved  in 
Canada    balsam  —  the    water   being   got   rid    of   by 


Fig.  86.— Urate  of  soda.     {AfUr 
Roberts.) 


Fig.  87.— Oxalate  of  lime.    (After  Finlayson.) 


drop 


passing   them  through   alcohol,    then  letting  a 
dry  on  the  slide,  and  adding  balsam  in  xyloL 

(4)   llippiiric    acid    a|)pears    in    human    urine 
ghiefly  after  the  administration  of  benzoic  acid  or  its 


332 


The   Urine. 


salts.      It  occurs  as  colourless  four-sided  prisms,  inso- 
luble in  hydrochloric  acid  but  soluble  in  ammonia. 

(5)  Oxalate  of  lime. — This  deposit  is  rarely 
abundant.  The  small  colourless  crystals  lying  on  the 
top  of  the  mucous  deposit  that  settles  at  the  bottom 
of  the  urine  glass  give  the  impression  of  an  undu- 
lating snowy  surface.  They  also  adhere  to  irregu- 
larities on  the  surface  of  the  glass,  producing  the 
appearance  of  scratches.      Two  forms  are  found  under 


Fig.  88. — a,  tyrosin  crystals  ;  ?>,  cystin  ;  c,  leucin. 


the  microscope.  The  first,  which  is  by  far  the 
commoner,  consists  of  small  octahedral  crystals. 
When,  as  is  generally  the  case,  they  are  slightly 
flattened  along  one  axis,  they  appear  like  squares 
crossed  by  two  diagonal  lines,  or  like  long  octahedra, 
according  as  the  short  axis  lies  in  or  perpendicular  to 
the  line  of  sight.  The  other  form  in  which  oxalates 
occur  is  that  of  minute  dumb-bells  or  oval  biscuit- 
shaped  discs.  Some  writers  consider  that  this  form 
is  not  really  due  to  oxalate  but  to  carbonate  of  lime ; 
yet,  though  carbonates  frequently  enough  assume  this 
shape,  there  can  be   little  doubt  that  under  certain 


Microscopical  Examina  tion. 


333 


eoiiditioiifs  oxalates  do  so  too.  For  permanent  speci- 
mens octahedral  oxalates  are  best  mounted  in 
glycerine  jell}",  dumb-bell  oxalates  in  balsam  (Fig.  87). 
(6)  Cystiii  is  a  rare  deposit  in  human  urine,  but 
when  it  occurs  the  precipitate  is  often  copious,  and  is 
not  unlike  a  sediment  of  fawn-coloured  quadri-urate. 
The  addition  of  a  few  drops  of  acetic  acid  to  a  urine 
containing  cystin  in  solution  determines  its  precipi- 
tation.     From    urine   it   is    deposited    as   hexagonal 


— stellar  phosphates.    {After  Finlayson.) 


tablets,  soluble  in  ammonia  and  re-crystallising  when 
the  ammonia  evaporates  as  hexagons  or  prisms 
(Fig.  88,  b). 

(7)  Xaiitliiii  is  of  extremely  rare  occurrence  ;  the 
crystals  are  said  to  be  similar  to  "  whetstone  "  crystals 
of  uric  acid,  but  are  soluble  in  ammonia,  in  warm 
hydrochloric  acid,  and  in  nitric  acid. 

(8)  Tyrosiaa  is  generally  found  associated  with 
leucin,  but  occurs  independently  also.  It  forms 
colourless  sheaves  of  fine  needle-like  crystals.  A 
similar  appearance  may  be  presented  by  several  other 
deposits  ;  therefore,  if  there  be   any  doubt  as  to  the 


334 


The   Urine. 


nature  of  the  sediment,  a  chemical  analysis  may  be 

necessary  (Fig,  '^%.,  a). 

(9)  Leiiciii  occurs  in   nrine   as  yellow  spherical 

masses  without  obvious  crystalline  structure.     Leucin 

and  tyrosin  occur  together  in  acute  yellow  atrophy  of 

the  liver  (Fig.  88,  c). 

In  alkaline  urine  the  following  occur  : — 

(1)  Phosphates. — These  may  either  be  salts  of 


Fig.  90. — Triple  phosphates.     {After  Finlayson.) 

phosphoric  acid  and  calcium,  or  of  phosphoric  acid 
with  ammonium  and  magnesium. 

(a)  Phosphate  of  lime  is  found  either  in  an  amor- 
phous or  a  crystalline  form,  the  latter  being  also 
known  as  stellar  phosphate  (Fig.  89). 

Amorphous  phosphate  of  lime  occurs  in  small 
white  granules,  as  a  deposit  at  the  bottom  of  alkaline 
urine.  To  the  naked  eye  the  sediment  is  white  and 
tiocculent ;  unlike  urates,  it  has  no  affinity  for  urinary 
pigment.     The  deposit  is  increased  on  heating. 

Stellar  phosphates  are  rather  uncommon.  They 
consist  of  colourless  plasmatic  crystals,  which  occur 
either  singly  or  more  often  in  radiating  clusters.  They 
are  found  in  very  faintly  acid  as  well  as  in  neutral 


MiCR  OS  CO  PIC  A  L    EXA  MINA  TION. 


335 


and  alkaline  urine.  Roberts  is  inclined  to  regard 
the  presence  of  this  deposit  in  abundance  as  an 
accompaniment  of  some  grave  disorder. 

(6)  Ammonium  magnesium,  or  "triple "  phos- 
phate, is  deposited  in  ammoniacal  states  of  the 
urine.  To  the  naked  eye  the  sediment  appears  very 
white,  and  when  the 
crystals  are  large  they 
may  be  visible  as  bright 
points.  Sometimes  the 
deposit  also  clings  to  the 
sides  of  the  glass  and 
forms  a  film  on  the  sur- 
face of  the  urine. 

The  crystals  are  in- 
complete, triangular, 
colourless  prisms,  which 
may  offer  considerable 
variations  in  appearance, 
according  to  their  length 

and  degree    of  perfection.  Fig.  91. -Deposit  in  alkaline  fermenta- 

Often  they  are   described  tlon    of   urine,  showing  urate    of 

,,^      .p           ,5,         ,,       n^  auimonia,  triple  phosphates,  and 

as  "  knife-rest     or  "  COitin-  bacterium  ure^e. 

lid  "  crystals.     If  the  am- 
moniacal change  is  well  marked,  and  still  more  if  ex- 
cess of  ammonia  is  added  to  healthy  urine,  the  deposit 
takes  the  form  of  feathery  stars,  and  is  then  known 
as  a  precipitate  of  "feathery"  phosphates  (Fig.  90). 

It  is  difficult  to  preserve  these  crystals  perma- 
nently, but  they  keep  fairly  well  in  a  solution  of 
ammonium  chloride. 

(2)  Urate  of  auiuiouia  occurs  in  alkaline 
urine,  and  is  very  commonly  present  in  cases  of  cys- 
titis. Microscopically  it  occurs  in  small  spherical 
masses  which  are  practically  indistinguishable  in 
many  instances  from  those  of  urate  of  soda,  except 
that  they  are  generally  darker  and  more  opaque,  and, 


33^ 


The   Urine. 


unlike  the  soda  salt,  are  associated  with  crystals  of 
triple  phosphate.  The  si)heres  may  have  smooth 
surfaces,  or  they  may  be  beset  with  innumerable 
spiny  processes  (Fig.  91). 

(3)  Carbonates  generally  occur  in  human  urine 


Fig.  92.  -Renal  epithelium.     {After  PmUHs.) 
a,  normal ;  b,  disintegrated  ;  c,  fatty. 

as  granular  particles,  which  dissolve  in  acetic  acid 
with  evolution  of  COo.  As  phosphates  give  off  no 
gas  on  solution  in  acetic  acid,  it  is  quite  easy  to 
distinguish  between  them.  On  rare  occasions  in 
human  urine,  and  commonly  in  horse's  urine,  car- 
bonate of  lime  appears  in  the  form  of  dumb-bells  or 
of  spheres  with  a  radiating  crystalline  structure. 

(4)  Cholesteriii  has  occasionally  been  found  in 
the  urine  ;  it  occurs  in  characteristic  thin,  rhom- 
boidal,  colourless  plates,  with  a  notch  at  one  of  the 
corners  (see  Fig.  133). 


Microscopical  Examination. 


337 


mmm§  mi 


■)iiKil 


Fig.   93. —  Epithelial  cells   from  tlie  uriuarj'-  passages.       (From    Sahli's 
"  Klinische  Untersuchungs-Methoden,"  after  Bizzozero.) 

a,  cells  of  the  deepest  layer  ;  b,  long  cells  of  the  second  layer ;  c,  "  tailed"  cells  ; 
d.  flat  cells  of  superficial  layer;  e,  r'.sr,  cells  of  superflcial  layer  in  surface 
view,  with  nuclei  and  indentations  ;  h,  i,  k,  I,  epithelium  from  bladder, 
altered  by  action  of  urine  ;  m,  cells  from  male  urethra. 


Other  sediments,  such  as  indigo,  lime  and  mag- 
nesia soap  crystals,  and  haematoidin  have  been 
observed,   but  are  of  little  importance. 


w 


338 


The   Urine. 


2. — Orjfaiiised  depoisits. 

(1)  Red  blo»d  corpuscles  are  present  in  cases 
of  haematuria,  but  under  certain  conditions  are 
rapidly  disintegrated,  and  should  therefore  be  ex- 
amined  for  in    recently   voided    urine.       According 


Fig.  94, — Tube  casts.    (After'iRoberts.) 
a,  epithelial ;   b,  granular 

to  the  density  of  the  urine  they  appear  fairly  normal, 
or  swollen,  or  shrunken  and  crenated. 

(2)  Leucocytes  a^nd  pus  corpuscles  occur 
where  there  is  irritation  and  suppuration  of  the 
urinary  tract.  According  to  the  length  of  time 
which  has  elapsed,  the  cells  may  be  indistinguish- 
able from  ordinary  leucocytes,  or  they  may  be  very 
granular  and  fatty.  The  addition  of  acetic  acid  clears 
up  the  cell  body  and  brings  two  or  three  nuclei 
iiito  view.     Where  pus  is  present,  examine  carefully 


Microscopical  Examination. 


339 


for  pathogenic  micro])es,  especially  for  gonococei  and 
tubercle  bacilli, 

(3)  In  cases  of  cliyluria  the  urine  contains 
nucleated  granular  corpuscles  similar  to  leucocytes, 
and  very  finely  divided  fatty  material  which  appears 


Fig.  95.— Tube  easts.     (^After  Roberts.) 
a  fatty  casts ;  b,  c,  blood  casts ;  d,  free  fatty  molecules. 


simply  granular  under  the  microscope.  A  few  red 
blood  corpuscles  are  often  present.  The  urine  and 
blood  should  be  carefully  examined  for  the  presence 
of  filariae,  particularly  if  the  patient  comes  from  a 
district  where  these  parasites  exist. 

In  lipiiria,  the  fat  may  occur  in  larger  globules 
which  refract  light  strongly,  and  which  are  sometimes 
free  in  the  fluid,  at  other  times  enclosed  in  cells 
or  tube  casts. 

It  must  not  be  forgotten  that  fatty  matter  may 


340 


The   Urine. 


reach  the  urine  unintentionally  from  an  oiled  catheter, 
or  may  be  added  purposely  in  the  form  of  milk  by 
a  patient  who  wishes  to  deceive  the  physician. 

(4)  Epithelium  from  various  parts  of  the  urinary 
tract  may  be  found  in  the  urine.  The  following 
varieties  are  readily  recognised  : — 

{a)  Renal  epithelium,.  This  is  polygonal,  nucleated, 


Fig.  96.— Hyaline  (a)  and  waxy  (6)  tube  casts.     (J/fer  Boherts.) 

and  rather  larger  than  a  leucocyte.  It  may  present 
fatty  degeneration,  or  be  more  or  less  disintegrated 
(Fig.  92). 

(6)  Epithelium  from  the  bladder  and  urhiary 
passages  presents  various  appearances,  according  to 
whether  it  is  derived  from  the  more  superficial  or 
deeper  layers.  Formerly,  tailed  cells  were  thought  to 
indicate    implication  of   the    pelvis    of   the    kidney ; 


Microscopical  Examination.  -i^^i 

this  is,  however,  inaccurate.  They  may  equally 
well  iDroceed  from  the  deeper  layers  of  the  bladder 
epithelium,  as  may  be  seen  from  the  accompanying 
diagram  (Fig.  93). 

(c)  Vaginal  epithelium  is  very  commonly  present 
in  the  urine  of  women.  It  is  squamous,  and  the  large 
cells  appear  sometimes  singly,  at  other  times  in  groups. 

(.5)  Spermatozoa  occur  at  times  in  the  urine, 
where  their  characteristic  appearance  makes  it  easy 
to  recognise  them. 

(6)  Prostatic  threads  are  found  when  there  is 
chronic  inflammation  of  the  prostate,  especially  after 
gonorrhoea.  They  consist  of  mucus,  and  are  mostly 
voided  with  the  first  portions  of  the  urine.  They  are 
much  larger  than  tube  casts,  being  visible  readily 
enough  to  the  naked  eye  as  they  float  in  the  urine  or 
on  its  surface. 

(7)  Tube  casts  (Figs.  94,  95,  96).— The  follow- 
ing classification,  which  is  more  satisfactory  than  those 
usually  adopted,  is  given  by  Prof.  Senator,  of  Berlin.* 

There  are  three  main  groups  of  tube  casts  : — 

1.  Casts  wholly  or  mostly  composed  of  cellular 
structures. 

2.  Granular  casts. 

3.  Amorphous  casts,  having  a  homogeneous  struc- 
ture, and  occasionally  striated  on  the  surface. 

Group  1.  Cellular. — The  cells  may  be  epithelial 
or  composed  of  red  blood  corpuscles  or  leucocytes. 

{a)  Epithelial.  The  casts  may  be  completely 
covered  with  epithelial  cells,  as  though  the  whole 
epithelium  had  scaled  off  a  tubule,  or  the  cells  may 
have  been  separately  detached  and  subsequently 
moulded.  The  cells  may  or  may  not  show  a  nucleus, 
and  they  may  appear  fresh,  or  affected  by  granular  or 
fatty  degeneration. 

*  "  Die  Erkrankungen  der  Nieren,"  in  Nothnagel's  "  Specielle 
Pathologie  unci  Therapie,"  vol.  xix. 


342  The  Urine. 

(b)  The  red  blood  corpuscle  casts  exhibit  a  surface 
thickly  covered  with  the  minute  round  corpuscles. 

(c)  Leucocytes  rarely  form  casts  by  themselves, 
but  are  pretty  often  found  adhering  to  the  surface  of 
other  casts. 

Group  2.  Oraiiiilar. — The  granules  are  some- 
times coarse,  at  other  times  fine.  They  are  sometimes 
fatty,  at  other  times  they  result  from  granular  degen- 
eration of  protoplasm.  They  represent  in  some  in- 
stances the  relics  of  broken-down  epithelium,  in  other 
cases  they  result  from  a  granular  change  occurring  in 
old  amorphous  tube  casts. 

Group  3.  Amorphoiis.  —  This  group  contains 
two  varieties,  the  hyaline  and  the  waxy. 

(a)  Hyaline  tube  casts  are  pale,  transparent,  and 
homogeneous.  Occasionally  the  surface  is  striated. 
They  may  be  almost  invisible,  but  are  rendered  more 
prominent  by  the  addition  of  iodine  solution.  Their 
origin  has  l)een  variously  accounted  for.  Senator 
believes  that  in  the  vast  majority  of  cases  they 
are  derived  from  epithelium  which  has  undergone 
hyaline  degeneration,  or  has  yielded  a  secretion  that 
is  coagulable. 

(b)  Waxy  casts  are  broader  and  more  highly  re- 
fractile  than  hyaline.  Often  they  are  more  or  less 
fissured.  Possibly  they  may  be  formed  from  other 
casts  which  have  remained  long  in  the  urinary  tu- 
bules; they  are  not  symptomatic  of  waxy  disease  of  the 
kidney.  Sometimes  tliey  give  the  amyloid  reaction 
with  iodine  and  sulphuric  acid,  and  with  methyl  violet. 

Transition  forms  between  the  various  groups  are 
not  uncommon ;  often,  for  instance,  a  cast  is  partly 
epithelial  and  partly  hyaline. 

A  tube  cast  frequently  picks  up  adventitious 
elements  from  the  urine,  and  thus  comes  to  contain 
bacteria,  or  crystals  such  as  oxalate  of  lime. 

In  length,  tube  casts  are  very  variable  ;  occasionally 


Microscopical  Examination.  343 

tliey  approach  a  millimetre  in  length.  One  end  may 
be  spirally  twisted  or  in  rare  cases  bifurcated.  Form- 
erly tube  casts  were  called  "fibrin  cylinders,"  but  now 
it  is  proved  that  fibrin  rarely  or  never  enters  into 
their  composition,  the  only  exception  being  that  in 
the  case  of  red  blood  corpuscle  casts  the  blood  discs 
may  be  bound  together  by  a  little  fibrin. 

Structures  called  cylindroicls  have  been  described 
by  Thomas  and  others.  They  resemble  extremely  long 
and  narrow  tube  casts,  but  are  usually  considerably 
flattened.  Very  various  estimates  have  been  formed 
of  their  significance,  some  observers  regarding  their 
presence  as  quite  immaterial,  others  looking  on  them 
with  considerable  suspicion  as  being  nearly  related, 
both  in  origin  and  clinical  import,  to  tube  casts. 
Senator  inclines  to  the  latter  view. 

Not  to  be  confounded  either  with  tube  casts  or 
cylindroids  are  the  small  strings  of  mucus  which 
occasionally  are  present  in  a  urinary  sediment.  Small 
clumps  of  micrococci  and  short  so-called  "prostatic 
threads  "  are  also  liable  to  be  misinterpreted  by  an 
inexperienced  observer.  When  there  is  reasonable 
cause  for  doubt,  the  addition  of  acetic  acid  or  some 
other  reagent  will  often  make  the  discrimination 
perfectly  simple. 

It  is  frequently  difficult  to  preserve  tube  casts 
permanently  for  microscopic  examination.  The  two 
methods  which  the  writers  have  found  most  serviceable 
are  : — (a)  Collect  some  of  the  sediment  containing  the 
casts,  wash  rapidly  in  water,  and  drop  into  a  conical 
glass  containing  picrocarmine  stain.  When  the  sedi- 
ment has  collected  at  the  foot  of  the  glass,  which  will 
have  occurred  in  twelve  hours  or  so,  wash  the  deposit 
once  more  in  water,  and  drop  it  into  a  small  quantity 
of  Farrant's  medium  in  a  conical  glass.  It  will  gradu- 
ally sink  in  this,  and  after  a  day  or  two  samples  can 
be  removed  from  the  foot  of  the  fluid,  and  permanently 


344  The  Urine. 

mounted  in  some  of  the  fluid  from  which  they  have 
been  withdrawn. 

(6)  Harris  proposes  the  following  method  :  Let 
urine  stand  for  twelve  hours,  then  remove  deposit, 
and  place  in  a  pipette  whose  upper  end  is  closed 
by  a  rubber  stopper.  The  pipette  should  contain 
the  following  preservative  fluid  : — 

Pot.  acetate  ...  ...  ...  60  grms. 

Chloroform ...  ...  10  cc. 

Distilled  water     ...  ...  ...      1,000  cc. 

When  the  sediment  has  sunk  through  the  fluid 
it  may  be  transferred  to  a  slide  along  with  a  drop 
of  the  preservative,  and  permanently  sealed  there. 
Specimens  keep  fairly  well. 

The  use  of  a  centrifuge  is  of  great  value  for  secur- 
ing tube  casts  in  perfectly  fresh  urine,  and  for 
washing  them  rapidly  in  water  prior  to  preserving  them. 

(8)  Tumours  of  the  bladder,  especially  when  villous, 
may  often  be  detected  by  the  presence  of  fragiiieiits 
of  the  growth  in  the  urine.  These  show  a  core  of 
connective  tissue  with  its  blood-vessels,  coated  with 
several  layers  of  nucleated  epithelial  cells.  In  can- 
cerous tumours,  though  their  debris  is  commonly 
enough  present^  yet  nothing  at  all  so  characteristic 
is  to  be  seen  as  is  found  in  the  papillomata. 

(9)  Elastic  fibres  are  often  present  in  cases  of 
ulceration  of  the  bladder.  They  may  be  detected 
either  without  special  treatment,  or  after  the  use  of 
caustic  soda,  as  was  described  in  Chapter  VI.  on  the 
"  Respiratory  System,"  after  a  preliminary  filtration 
of  the  yet  acid  urine  to  remove  the  phosphates,  which 
would  otherwise  be  precipitated  copiously  when  an 
alkali  was  added. 

The  parasites  that  infest  the  urinary  tract  are 
in  temperate  climates  neither  numerous  nor  common. 
Senator"^  enumerates  the  following : — Echinococcus, 
*  Loc.  cit..  p.  420,  ct  scq. 


MiCR  O  SCO  PIC  A  L    EXA  MINA  TION. 


345 


cysticerciis  cellulosse,  eustrongjlus  gigas,  distoma  (oi' 
Bilharzia)  lia?matobiuin,  filaria  sanguinis  liominis, 
nephropliages  sanguinarius  (a  menilDer  of  the  arthro- 
pod a  related  to  the  acari),  rhabditis  (sp.  ?),  and  certain 
psorosperms.  Several  of  these  are  of  such  extreme 
rarity  as  to  be  of  no  practical  importance  ;  echino- 
coccus,  cysticercus,  and  filaria  having  been  described 


Fig.  i^tT.— Ova  of  Bilharzia  haematobium  in  urine.     {After  Roberts.) 
a,  X  5i»  in  mucus  ;  b,  x  lOij  in  urine  freshly  voided. 

elsewhere,"^  distoma  h^matobium  alone  needs  to  be 
referred  to  in  this  chapter. 

D.  hcematohium.  The  ova  measure  0*12  mm.  by 
0'04  mm.  A  spine  projects  at  one  pole  or  at  a  little  dis- 
tance from  it.  In  urine  the  spine  is  usually  situated  at 
the  pole ;  the  form  with  a  lateral  spine  predominates 
in  ova  obtained  from  the  rectum  (Fig.  97). 

The  adult  male  Bilharzia  is  thicker  and  shorter 
than  the  female,  and  is  provided  on  the  ventral  sur- 
face with  a  gynsephoric  canal.  The  female  is  cylin- 
drical and  wormlike.  The  male  measures  12  mm., 
the  female  about  16  mm.,  in  length.  Their  habitat  is 
in  the  blood-vessels  of  the  portal  system  and  in  the 

*  Pp.  92  and  204. 


346  The  Urine. 

venous  plexuses  of  the  bladder  and  rectum.  The  ova 
escape  from  the  blood-vessels  into  the  tissues  of  the 
body.  Those  which  reach  the  rectum  and  bladder  are 
discharged,  and  enable  a  diagnosis  to  be  made.  The 
parasite  is  very  common  in  Egypt,  where  nearly  a 
fourth  part  of  the  native  population  are  supposed  to 
suffer  from  it. 

After  the  urine  has  been  voided  for  some  time,  it 
becomes  contaminated  by  numerous  non-pathogenic 
fungi  and  infusoria  ;  but  several  pathogenic  bacteria 
occur  in  the  urinary  tract,  and  in  cases  of  doubt 
should  always  be  sought  for.  The  chief  of  these  are 
the  gonococcus,  the  tubercle  bacillus,  which  must  not 
be  mistaken  for  the  morphologically  similar  smegma 
bacillus,  and  the  bacillus  coli  communis. 

In  cases  of  cystitis  a  great  variety  of  bacteria  may 
occur.  Actinomyces,  though  rarely  present  in  the 
kidney,  has  been  found  there. 

ForeJg-n  toodies  often  occur  in  urine  which  has 
been  set  aside  for  examination.  Besides  hairs, 
feathers,  moth-wing  scales,  cotton,  woollen,  and  silk 
fibres,  starch  grains  derived  from  dusting  powders — 
and  readily  recognised  by  their  turning  blue  on  the 
addition  of  a  little  dilute  tincture  of  iodine  —  and, 
more  confusing  than  any  of  these,  pinewood  dust 
swept  from  the  floor — one  occasionally  finds  fragments 
of  the  contents  of  dermoid  tumours  or  abscesses  that 
have  opened  into  the  bladder  or  ureter.  Small  shreds 
of  striped  muscle  may  in  rare  instances  be  voided  with 
the  urine,  and  are  derived,  in  some  cases  at  least,  from 
a  sloughing  psoas  abscess. 

It  may  happen  also  that  the  patient  has  been  sick, 
and  sputum  or  vomited  matter  may  be  more  or  less 
abundantly  mixed  with  the  urine.  If  these  sources 
of  contamination  are  forgotten,  there  is  a  risk  of  very 
erroneous  interpretations  being  given  of  not  a  few 
urinary  deposits. 


347 


CHAPTER    YIII. 
The  Skin. 

For  the  examination  of  the  skin  and  its  appendages 
the  patient  should  be  stripped  as  completely  as  cir- 
cumstances permit  and  placed  in  a  good  light. 

One  should  first  note  the  colour  of  the  skin  as  a 
whole.  In  anaemia  the  skin  is  pale;  in  chlorosis  it 
has  a  greenish  tint ;  in  pernicious  anaemia  it  is  lemon 
yellow.  In  order  to  distinguish  the  yellowness  of  per- 
nicious anaemia  from  jaundice,  look  at  the  conjunctiva. 
The  best  way  to  do  that  is  to  place  one  hand  on  the 
patient's  forehead,  ask  him  to  look  at  the  ground,  and 
then  raise  the  upper  eyelid  with  the  thumb.  In  jaun- 
dice the  conjunctiva  is  seen  to  be  yellow  where  it 
covers  the  sclerotic  ;  in  anaemia  it  is  white.  In  judging 
of  the  degree  of  anasmia,  one  should  be  guided  more 
by  the  colour  of  the  mucous  membranes  than  by  that 
of  the  skin  itself.  The  conjunctiva  lining  the  lower 
eyelid  is  most  usually  taken  as  an  index.  It  is  easily 
seen  by  getting  the  patient  to  look  up  while  one 
depresses  the  lower  lid  with  one  finger.  Instead 
of  being  pale,  the  skin  may  be  abnormally  red  or 
flushed.  The  flushing  may  be  general  or  local.  Its 
exact  extent  should  always  be  noted,  and  whether 
or  not  it  fades  on  pressure.  The  best  way  of  telling 
whether  any  redness  of  the  skin  fades  on  pressure  or 
not  is  to  place  a  lens  on  the  skin  and  press  it  down. 
It  will  then  be  seen  whether  or  not  the  skin  becomes 
pale  under  the  lens. 

The  term  tache  c^r6brale  is  applied  to  the 
red  flush  which  appears  in  some  cases  of  intracranial 
disease  when  the  skin  is  stimulated.     To  elicit  its 


348  The  Skin. 

presence,  di^aw  the  finger  nail  firmly  across  the  patient's 
forehead.  A  red  line  soon  develops  along  the  track 
of  the  nail,  and  persists  for  some  time.  It  is  due  to  a 
disordered  vasomotor  supply,  but  is  found  in  other 
conditions  besides  those  of  cerebral  irritation,  and 
is  therefore  not  of  much  diagnostic  value. 

Rarer  alterations  in  colour  of  the  skin  are  those 
due  to  the  taking  of  nitrate  of  silver  and  those  which 
occur  in  Addison's  disease.  The  former  constitutes 
what  is  known  as  argyria.  It  consists  in  a  leaden 
grey  hue  of  the  whole  skin,  which  is  unaffected  by 
pressure.  The  pigmentation  of  Addison's  disease 
consists  in  a  bronzing,  which  appears  first  on  parts  in 
contact  with  the  air,  and  next  on  those  which  are  ex- 
posed to  pressure.  It  is  made  up  of  small  brownish 
spots,  which  fade  off'  at  their  margins  into  healthy 
skin.  The  lips  and  buccal  mucous  membrane  should 
always  be  examined  in  cases  of  supposed  bronzing.  In 
Addison's  disease  they  often  exhibit  marks  of  pig- 
mentation of  a  dark  bluish -black  colour,  which  have 
been  compared  to  the  stains  produced  by  sucking 
a  pen. 

Having  noted  any  alteration  in  the  colour  of  the 
skin,  one  should  look  for  the  presence  of  any  erup- 
tion. If  any  such  be  observed,  the  patient  should  be 
questioned  about  it  on  the  lines  laid  down  on  p.  9. 
The  exact  situation  and  extent  of  the  eruption  should 
be  noted,  and  whether  it  is  symmetrical  or  confined 
to  one  side  only.  These  general  facts  having  been 
noted,  one  should  pass  to  a  description  of  the  minute 
characters  of  the  eruption.  In  order  to  do  this,  it 
must  be  borne  in  mind  that  every  cutaneous  eruption 
consists  of  a  **  primary  lesion, "  to  which  secondary 
lesions  may  or  may  not  be  superadded.  The  following 
is  a  description  of  the  different  primary  lesions  which 
may  be  met  with. 

(1)  macules  or  spots. — Any  abnormal  change  in 


Lesions.  349 

the    colour    of   the  skin    confined  to  a   limited  area. 
Always  note  whether  or  not  they  fade  on  pressure. 

(2)  Papules. — Solid  projections  above  the  sur- 
face, which  are  not  larger  than  a  pea.  The  term 
tubercle  is  applied  to  any  solid  projection  from  the 
skin  which  is  larger  than  a  pea  but  not  larger  than  a 
cherry.  Anything  larger  than  that  is  called  a  tumour. 
Always  note  whether  the  top  of  a  papule  is  rounded, 
pointed,  or  flattened.  As  regards  the  base,  observe 
whether  it  infiltrates  the  skin  widely  or  not. 

(3)  Vesicles. — Elevations  of  the  horny  layer  of 
the  epidermis  by  transparent  or  milky  fluid  which 
are  not  larger  than  a  pea.  If  larger  than  that  they 
should  be  described  as  bullae  or  blebs.  Always 
note  whether  or  not  there  is  an  area  of  redness  around 
the  base  of  a  vesicle. 

(4)  Pustules.  —  Small  elevations  of  the  skin 
containing  pus.  Always  observe  whether  there  is 
much  infiltration  around  them  or  not. 

(5)  Wheals. — Slightly  elevated  portions  of  skin, 
the  centre  of  which  is  paler  than  the  periphery. 

Having  stated  which  of  these  primary  lesions  it  is 
that  composes  the  eruption,  one  should  next  note 
whether  the  lesions  are  isolated  (discrete),  or  whether 
they  run  together.  It  must  also  be  remembered  that 
an  eruption  may  be  made  up  of  more  than  one  kind 
of  primary  lesion.  Thus  papules  may  be  mingled 
with  pustules,  or  pustules  with  vesicles,  and 
so  on. 

Next  look  for  secondary  lesions.  These  are 
either  produced  mechanically  or  are  the  result  of 
changes  which  take  place  in  the  primary  lesion  in  the 
course  of  its  growth  or  decline.  The  commonest 
secondary  lesions  of  mechanical  production  are 
excoriations  due  to  scratching  and  fissures 
(rhagades) — deep  cracks  going  down  to  or  through 
the  coriumj  and  produced   by  the  stretching  of   the 


35°  The  Skin. 

skin  after  it  has  become  inelastic  owing  to  infiltration. 
Fissures  are  often  very  painful. 

The  following  are  the  secondary  lesions  produced 
by  changes  in  those  which  are  ]5rimary. 

(1)  Desquamation. — If  the  primary  lesion  be 
a  dry  one  (macules  or  papules),  a  mere  scaling  off  of 
epidermic  cells  occurs,  and  the  eruption  is  then  said 
to  be  "  scaly.'' 

In  moist  lesions  (vesicles,  pustules,  bullae)  the 
epidermic  cells  become  glued  together  by  the  dried 
fluid,  and  a  scab  or  crust  forms.  The  scab  may  be 
serous,  purulent,  hsemorrhagic,  or  sebaceous,  accord- 
ing to  the  nature  of  the  contents  of  the  primary 
lesion. 

(2)  InliUratJoii  may  occur  around  the  primary 
lesions  leading  to  the  production  of  a  leathery  feeling 
in  the  skin.  This  is  usually  the  result  of  prolonged 
chronic  inflammation. 

(3)  Pigmentation  may  occur  around  the  prim- 
ary lesions.  This  is  also  usually  due  to  prolonged 
inflammation. 

(4)  Ulceration. — Due  to  breaking  down  of  the 
primary  lesions  and  destruction  of  a  part  of  the 
true  skin. 

The  points  to  note  in  describing  an  ulcer  are  (1) 
the  nature  of  the  floor  of  the  ulcer  and  the  granula- 
tions covering  it;  (2)  the  character  of  the  edge — 
smooth,  raised,  undermined,  etc.  ;  (3)  the  discharge 
■ — is  it  serous,  purulent,  watery,  fetid,  etc.  1  (4)  the 
character  of  the  surrounding  skin,  whether  indurated, 
pigmented,  etc. 

(5)  Scar  formation.^This  only  occurs  where 
the  true  skin  has  been  involved,  i.e.  wliere  there  has 
been  an  ulcer.  Describe  the  scar,  noting  especially 
whether  it  be  thin  or  thick,  freely  movable  or  ad- 
herent to  the  deeper  tissues,  pale  or  livid,  pitted  or 
not,  surrounded  by  a  zone  of  pigmentation  or  not. 


Palpation.  351 

Proceed  now  to  the  palpation  of  the  skin.  Pass 
the  hand  gently  over  it,  pinching  it  up  between 
the  forefinger  and  thumb,  and  note  the  following 
points  : — 

Is  it  smooth  or  rough,  thin  or  thick,  dry  or 
moist  %  If  there  be  any  visible  sweating,  note 
whether  it  is  general  or  local  ;  whether  it  is  attended 
or  not  by  any  flushing  of  the  skin  ;  and  whether  the 
sweat  has  any  particular  odour. 

The  elasticity  of  the  skin  should  be  investigated. 
If  a  fold  of  healthy  skin  is  pinched  up  it  immediately 
flattens  itself  out  again  when  released.  Sometimes, 
however,  it  only  does  so  very  slowly,  remaining  for 
a  considerable  time  in  a  creased  condition.  This 
indicates  a  diminished  elasticity.  It  occurs  not 
infrequently  in  debilitated  and  in  old  persons. 

The  condition  of  the  subcwtaiieous  tissue 
should  also  be  investigated.  It  may  be  infiltrated 
with  fluid  (oedema),  with  solid  material  (as  in 
myxoedoma),  or  with  air  (subcutaneous  or  surgical 
emphysema).  The  presence  of  oedema  is  usually 
recognised  by  the  fact  that  if  the  skin  be  pressed 
with  the  finger,  especially  over  a  hard  body  such 
as  a  bone,  a  pit  is  left  which  persists  for  some 
little  time.  It  must  be  borne  in  mind,  however,  that 
this  is  not  an  invariable  guide.  In  some  cases  of 
oedema  no  pitting  can  be  produced.  This  is  specially 
apt  to  be  the  case  where  the  oedema  is  one  of  very 
long  standing.  The  best  place  to  look  for  slight 
degrees  of  oedema  in  cai'diac  disease  is  behmd  the 
malleoli  of  the  tibia  and  fibula.  In  chronic  renal 
disease  oedema  can  often  be  earliest  detected  below  the 
conjunctiva.  This  subconjunctival  oedema  is  seen  by 
pushing  up  the  lower  lid  over  the  sclerotic.  A  little 
drop  of  fluid  resembling  a  tear  is  then  squeezed  up 
underneath  the  conjunctiva  over  the  sclerotic. 

Subcutaneous  emphysema     gives    rise    on 


Fig.  98.— Animal  parasites  of  skin. 


.^f^"* 


X    17-OIAM. 


a,  (lea;  h,  Pediculus  capitis^ ;  h',  ovum  of  ditto,  with  eml)ryo  ("nit");  c  P 
corporis;  f/,  P.  pubis;  e,  Acarus  scabiei  (female,  male,  ovum,  larva);  /! 
Demodex  folliculorum. 


Parasitic  Diseases. 


jDv) 


palpation  to  a  crackling  sensation,  wliich  has  been 
compared  to  that  which  is  experienced  in  handling 
a  bag  of  feathers. 

J^Iicroscopic  exainiiiation  of  the  skin  and  its 
appendages  is  confined  to  the  diagnosis  of  some 
parasitic  diseases,  of  which  the  following  are  the 
chief  (Fig.  98)  :— 

(1)  Scabies  or  itcli. — This  is  due  to  the  acarus 
scabiei.  The  female  acarus  is  larger  than  the  male, 
and  forms  burrows  in  the  skin  in  which  the  eggs 
are  deposited.  These  burrows  should  be  looked  for 
betsveen  the  fingers  and  on  the  inner  aspects  of 
the  wrists.  They  are  recognised  with  the  naked  eye 
as  little  short  dark  lines  terminating  in  a  sort  of 
shining  spot  of  skin.  The  eggs  He  in  the  dark 
line ;  the  insect  in  the  shining  spot.  It  may  be 
picked  out  by  means  of  a  flat  surgical  needle  passed 
along  the  black  line  to  the  clear  spot.  The  use  of 
a  lens  aids  the  operation,  and  permits  of  the  recogni- 
tion of  the  insect.  The  latter  may  be  placed  on  a 
slide  under  the  microscope  for  more  minute  inspection 
(Fig.  98,  e). 

(2)  Pediculosis. — Three  varieties  of  pediculus 
occur.  Pediculus  capitis  on  the  head,  P.  corporis 
on  the  trunk,  P.  pubis  on  the  pubic  and  axillary 
hairs.  The  eggs  or  "nits  "  of  the  P.  capitis  are  stuck 
on  to  the  hairs  (Fig.  98,  b' ).  From  their  position  on 
the  hairs  one  can  judge  of  the  duration  of  the  con- 
dition, for  they  are  fixed  on  at  first  near  the  root  of 
the  hair,  and  are  then  carried  up  with  the  latter  in 
its  gi'owth.  The  higher  up  the  nits  are,  therefore, 
the  longer  have  pediculi  been  present.  The  P.  corporis 
should  be  looked  for  in  the  seams  of  the  clothes, 
especially  where  the  latter  come  into  close  contact 
with  the  skin^e.^.  over  the  shoulders. 

The  microscopic  characters  of  the  pediculi  are 
shown  in  Fig.  98,  and  require  no  verbal  description. 

X 


354  The  Skin. 

It  will  be  noticed  that  the  P.  corporis  is  the 
longest  and  narrowest  of  the  three,  the  P.  pubis  is 
shoj'test  and  broadest,  and  the  P.  capitis  is  between 
the  two  in  size.  The  P.  pubis  is  also  distinguished 
from  the  others  by  being  yellowish-brown  in  colour. 
P.  capitis  and  P.  corporis  are  both  greyish  in  colour, 
though  the  latter  varies  considerably  with  the  colour 
of  the  skin  of  its  host.  The  shape  of  the  thorax  and 
abdomen  forms  a  distinguishing  character  between 
P.  capitis  and  P.  corporis  (Fig.  98,  6,  c,  d). 

(3)  Ring- worm.— Recent  investigation  by  Sabour- 
aud  and  others  has  shown  that  two  distinct  classes  of 
parasite  are  capable  of  producing  the  appearances 
which  are  included  under  the  name  "  ringworm." 
One  of  these  is  not  a  trichophyton.  It  goes  by 
the  name  of  imc7'osporon  Audouini,  and  is  the  cause 
of  the  commonest  and  most  contagious  and  intract- 
able form  of  the  disease.  Its  operations  are  chiefly 
confined  to  the  scalp,  but  90  per  cent,  of  all  cases 
of  ringworm  in  that  situation  are  due  to  its  presence. 
The  other  parasite  belongs  to  the  trichophyton 
family,  but  it  is  probable  that  there  are  several 
varieties  of  it.  It  is  the  commonest  producer  of 
ringworm  of  the  beard  and  skin  (tinea  circinata), 
but  only  occurs  in  about  10  per  cent,  of  the  cases 
of  ringworm  of  the  scalp.  It  succumbs  much  more 
readily  under  treatment  than  does  the  microsporon. 
The  trichophyton  is  characterised  microscopically 
by  having  fairly  large  spores,  which  are  arranged 
in  chains,  and  the  joints  of  its  mycelium  are  placed  at 
regular  intervals.  The  microsporon  has  small  spores, 
which  are  scattered  irregularly,  and  the  joints  of  its 
mycelium  are  at  unequal  intervals  (Fig.  99). 

A  useful  method  of  detecting  hairs  which  are 
affected  by  ringworm  consists  in  dabbing  over  the 
diseased  patch  with  a  piece  of  wool  soaked  in 
chloroform.       On    evaporation    of    the    latter,    the 


Parasitic  Diseases. 


355 


afiected  liaiis  are  Avhitened,  and  louk  as  if  cuxered 
witli  Iiuar  frost.  Tliey  can  thus  readily  be  dis- 
tinguished from  healthy  liairs  of  the  same  size  by 
the  aid  of  a  lens.  Hairs  affected  by  favus  are  not 
similarly  whitened  by  chloroform. 

Microscopic  examination. — If  one  is  dealing  with 
a  j^atch  of  ringwoiTQ  of  the  skin,  it  is  sufficient  to 
scrape  off  some  of  the  scales  with  a  blunt  penknife,  to 
place  them  in  a  drop  of  10  per  cent,  liquor  potassse, 
and  cover.  The  mycelium  of  the  fungus  will  be 
recognised  as  branching,  refractile  threads,  amid 
whicli  the  spores  are  scattered  in  groups  or  rows. 


Fig.  99.— Vegetable  parasites  of  tlie  skin. 

a,  Favus  {Achorion  Schonleivii),  sliowiufr  the  parasite  and  an  affected  liair  ;  b. 
Ringworm  (Micro^poron  Audoiiini),  showing  low-  and  liigh-power  viow  of 
affected  hairs  ;  c,  Pityriasis  versicolor,  showing  theniicrosporon  furfur,  x  800. 


356  The  Skin. 

If  a  hair  be  similarly  examined,  it  will  be  found 
to  be  broken  up  and  full  of  spores  (Fig.  99,  h).  No 
mycelium  can  be  seen.  For  diagnostic  purposes,  it 
suffices  to  wash  the  hair  in  ether  and  then  to  soak  it  for 
15  minutes  in  liquor  potassse.  The  spores  will  be  seen 
in  the  substance  of  the  hair  and  in  its  sheath.  Fatty 
particles  are  the  only  thing  likely  to  be  mistaken  f  jr 
them.  A  drop  of  ether  will  dissolve  fat  particles  but 
leaves  the  spores  unaffected.  Liquor  potassse,  how- 
ever, causes  the  spores  to  swell.  Its  use  should 
therefore  be  avoided  if  one  wishes  to  distinguish  the 
two  varieties  of  fungus.  For  that  purpose  staining  is 
of  great  help.     It  should  be  carried  out  as  follows  : — 

(1)  Remove  an  affected  hair  by  means  of  a  broad- 
pointed  pair  of  forceps. 

(2)  If  very  greasy,  wash  it  for  a  few  seconds  in 
ether  or  benzol. 

(3)  Steep  the  hair  for  an  hour  in  a  mixture  of  10 
parts  of  a  5%  alcoholic  solution  of  gentian  violet  and 
30  of  aniline  water  (Appendix,  24). 

(4)  Dry  the  hair  between  blotting-paper,  and 
steep  in  Gram's  solution.  This  fixes  the  stain  for 
5-10  minutes. 

(5)  Dry  again,  and  then  soak  for  10  minutes  in 
pure  aniline  to  which  enough  iodine  has  been  added 
to  give  it  a  distinctly  brown  colour.     This  decolorises. 

(6)  Wash  in  pure  aniline  for  a  few  seconds,  then 
in  xylol,  and  mount  in  balsam. 

On  examination  with  the  high  power  the  two 
varieties  of  fungus  can  be  differentiated  by  the 
characters  already  described.  It  should  be  noted 
that  the  difference  in  size  of  the  spores  of  the  two 
varieties  is  really  not  very  great,  after  all.  The 
arrangement  of  the  spores  and  the  character  of  the 
mycelium  are  the  points  to  which  attention  should 
be  directed. 

4.   Favus. — This    is    produced    by   the  achorion 


Parasitic  Diseases.  357 

ScLonlemii,  which  consists  of  a  long  branching  myce- 
lium with  rather  large  spores  arranged  in  rows  or 
groups.  If  a  favus  crust  and  the  accompanying 
hair  be  examined  in  caustic  potash,  the  hair  is  seen 
to  differ  from  one  affected  by  ringworm  in  being  full 
of  mycelium.  One  can  often  see  air  bubbles  being 
chased  out  of  the  mycelium  as  the  liquor  potassae 
finds  its  way  in.      The  medulla  of  the  hair  is  absent. 

The  hair  may  be  stained  by  the  method  described 
above.  The  long,  wavy,  branching  mycelium  will  be 
easily  seen,  and  a  few  rather  large  spores  in  rows  or 
in  grotips  (Fig.  99,  «). 

5.  Tiuea  versicolor. — This  is  produced  by  the 
microsporon  furfur.  A  scraping  should  be  examined 
in  caustic  potash.  The  fungus  shows  a  refractile 
mycelium  which  interlaces  freely  and  includes  bunches 
of  round  spores  in  its  meshes  (Fig.  99,  c).  The 
spores  may  be  stained  with  saffranin,  differentiated 
by  weak  acetic  acid,  and  the  mycelium  counterstained 
with  raethylen  blue. 

6.  Deniodex  follieuloniiii  (Fig.  98,  /)  is  a 
minute  acarus  about  y-^^  in.  in  length,  which  is  some- 
times found  in  the  sebaceous  contents  of  comedones. 
It  has  a  disproportionately  large  abdomen  marked 
with  transverse  rings,  which  give  it  at  first  sight 
the  appearance  of  a  minute  worm.  It  possesses  a 
suctorial  proboscis  and  styliform  jaws,  and  from  the 
thoracic  portion  of  the  body  four  pairs  of  stunted 
legs  project.  It  is  simply  a  parasite  lining  in  sebaceous 
matter,  and  is  of  no  pathological  importance. 


358 


CHAPTER    IX. 

Nervous  System. 

SECTION  I.— ANATOMY  AND   PHYSIOLOGY 
OE  THE  NERYOUS  SYSTEM. 

Much  recent  knowledge  regarding  the  structure 
and  mechanism  of  the  central  nervous  system  is  still 
too  unsettled  to  admit  of  being  used  at  the  bedside ; 
but  if  the  student  wishes  to  investigate  a  case  of 
nervous  disease  intelligently  he  must  first  have  a 
clear  grasp  of  some  well-established  facts  in  the 
anatomy  and  physiology  of  the  brain  and  spinal  cord. 
A  few  paragraphs  devoted  to  these  subjects  will 
therefore  not  be  out  of  place. 

(1)  Anatomy  and  physiology  of  the  motor 
and  sensory  paths. — The  student  will  remember 
that  the  motor  area  of  the  brain  is  situated  round  the 
fissure  of  Rolando,  the  leg  centre  being  highest  up,  the 
arm  centre  next  to  it  and  the  centres  for  the  face,  lips 


F  B  ONTA  t 


Fig.  100.— Outer  aspect  of  Right  Hi'iuispliore,  .showing  coiivolution.s. 


Anatomy  of  Brain. 


359 


and  tongue  l>eiiig  lowest.  Stated  more  exactly,  it  may 
1)6  said  that  the  movements  of  the  lower  limlj  are 
presirled    over   by  the  upper  ends  of  the  ascending 


Fig.  101. — Outer  aspect  of  Left  Hemisphere,  showing  functional  areas. 

frontal  and  ascending  parietal  and  the  posterior  end 
of  the  marginal  convolution  ;  the  movements  of  the 


V.  OBT 


Fig.  102.— Mesial  aspect  of  Right  Hemisphere,  showing  convolutions. 

upper  limb  by  the  middle  third  of  the  ascending 
frontal  convolution,  the  posterior  end  of  the  superior 
frontal,  the  middle  third  of    the  ascending  parietal 


36o 


Nervous  System. 


(for  the  hand  and  wrist),  and  part  of  the  marginal 
convolution  lying  posteriorly  to  the  part  which  supplies 
the  head.     The  head,  neck,   and  face  are  supplied  by 


Fig.  103.— Mesial  aspect  of  Left  Hemispliere,  showing  functional  areas. 


the  lower  part  of  the  ascending  frontal  and  by  the 
posterior  extremities  of  the  middle  and  inferior 
frontal  convolutions.  Also  by  a  small  part  of  the 
anterior  extremity  of  the  marginal  convolution.  The 
trunk  muscles  are  supplied  by  that  part  of  the 
marginal  convolution  which  lies  bet\'i  een  the  centres 
of  supply  for  the  leg  and  arm  (Figs.  100,  101,  102, 
103). 

The  motor  fibres  start  from  the  pyramidal  cells 
in  the  above  convolutions  and  pass  in  the  white  matter 
of  the  hemispheres  to  the  internal  capsule  {i.e.  the 
knee-shaped  band  of  white  matter  which  is  bounded 
on  its  outer  side  by  the  lenticular  nucleus  and  on  its 
inner  side  by  the  optic  thalamus  and  caudate  nucleus). 
The  motor  fibres  occupy  the  anterior  two-thirds  of  the 
posterior  limb  of  the  internal  capsule,  the  fibres  for  the 
face  being  farthest  forward,  those  for  the  leg  farthest 
back,  the  fibres  for  the  arm  being  between  (-Fig.  104). 
It  is  in  the  internal    capsule  that  haemorrhage  most 


The   Mo  tor    Pa  th. 


361 


fiequeiitly  occurs,  and  owing  to  the  close  approxima- 
tion of  all  the  fibres  at  this  point,  a  comparatively 
small  lesion  is  aVjle  to  produce  a  widespread  result. 


Fig.  104. — Diagram  to  show  relative  positions  of  the  face,  arm,  and  leg 
fibres  in  their  course  from  coitos  to  eras.  Tlie  section  through  the 
cortex  ami  crus  is  vertical  ;  through  the  internal  capsule  it  is  hori- 
zontal ;  *  indicates  the  elbow  of  the  internal  capsule. 

/,  face  ;  «,  arm  ;  \.  leg  fltires. 


From  the  internal  capsule  the  motor  jB.bres  descend  to 
the  crus  cerebri  occupying  the  middle  third  of  its 
anterior  aspect.  As  they  descend  in  the  crus  tho 
fibres  for  the  leg  are  to  the  outer  side,  the  fibres 
for  the  face  are  nearest  the  middle  line,  and  those  for 
the  ami  are  between  the  two.  Entering  the  pons,  the 
fibres  are  no  longer  quite  on  the  surface  but  are 
covered  by  a  layer  of  transversely  placed  fi.bres.  In 
the  upper  part  of  the  medulla  they  form  a  well-marked 
bundle,  the  anterior  pyramid,  lying  quite  on  the  surface. 
At  tlie  lower  part  of  the  medulla  the  greater  numl>er 
of  the  fibres  cross  to  tlie  opposite  side,  forming  what 


362 


Ner  vo  us  Sys  tem. 


is  known  as  the  "  decussation  of  the  j^yramids"  and 
run  down  in  the  crossed  pyramidal  tract  of  the  cord 
to  end  at  diflferent  levels  in  the  grey  matter  of  the 
anterior  cornu  (Fig.  105).  The  motor  impulses  are 
here  transferred  to  the  cells  of  the  anterior  cornu  and 
^  conveyed   by  their  fibres 

y^     ^^(y,  to  the  anterior  roots,  and 

thence  to  the  motor  nerves 
and  muscles.  The  small 
number  of  fibres  which  do 
not  decussate  in  the 
medulla  are  continued 
down  in  the  anterior  or 
direct  pyramidal  tract, 
and  end  in  the  anterior 
cornu  of  grey  matter. 
Some  of  them  also  de- 
scend in  the  crossed 
pyramidal  tract  of  the 
same  side. 

It  must   also   be    re- 
Fig.   105.  —  Diagram    showing   the   membered    that    a    small 

course  ofthe  motor  fibres  from  the  number    of     motor    fibres 

cortex  to  the  cord.  j  j 

c  c,  corpsus    callosuni ;   c   n,   caudate  ^lo    not     deCUSSate    at    all, 

leus ;   I  R,   Island    of   Reil;    C  ?,  "l-mf     c^r\A     in     +Vifi    ar»f(=>rinv 

istrum,  *  Site  of  facial  decussa-  ^^^    ^^^    1"    ^^®    antenoi 

cornu  of  the  same   side. 

This,  perhaps,  explains 
the  fact  that  after  a  unilateral  central  lesion  the 
knee  jerk  on  the  same  side  may  be  exaggerated  as 
well  as  that  of  the  opposite  leg. 

In  thus  tracing  the  course  of  a  motor  impulse,  we 
have  spoken  of  nerve  cells  and  nerve  fibies.  It 
would  be  better,  however,  to  discard  these  names  in 
favour  of  the  more  recent  terminology,  which  describes 
a  nerve  cell,  its  dendritic  processes,  and  the  fibre  con- 
nected with  it  (axis  cylinder  process)  as  a  '^  neuron/' 
Thus,  anatomically,  the  motor  impulses  are  conveyed 


Vil 

Nerue 


C.F 


nucleus 

Glaus 

tion  ;  c  p  T,  crossed  pyramidal  tract 

DPT,  direct  pyramidal  tract. 


The   Motor    Path. 


363 


by  means  of  two  neurons. 
One  of  these  is  tlie  pyra- 
midal cell  in  the  cerebral 
cortex  and  the  motor  fil)re 
arising  from  it  {i.e.  its  axis 
cylinder  process)  and  end- 
ing in  the  anterior  cornu. 
The  other  is  the  anterior 
cornual  cell,  and  the  fibre 
arising  from  it  and  ending 
in  the  muscle.  There  is 
apparently  no  direct  ana- 
tomical continuity  between 
these  two  neurons,  but  the 
nerve  impulse  is  able  to 
pass  from  the  one  to  the 
other  by  contact  (Fig. 
106). 

This  conception  has  also 
the  advantage  of  making 
clearer  some  well-known 
physiological  and  patho- 
logical facts.  Thus  it  can 
easily  be  understood  that 
if  one  part  of  a  neuron  be 
injured  the  health  of  the 
Tvhole  neuron  suffers.  If, 
for  example,  what  one  may 
call  the  body  of  the  upper 
neuron  [i.e.  the  cortical  cell) 
be  injured,  the  axis  cylinder 
process  of  the  neuron  [i.e. 
the  motor  fibre)  is  also 
affected,  and  ultimately 
undergoes  the  process 
spoken  of  as  degeneration. 
Conversely,     if     a     motor 


c: 


Fii^.     106.  —  Upper    and    Lower 
Neurons  of  Motor  patli. 

c  c,  cerebral  cell;  s  c,  spinal  cell; 
s,  sensory  fibre ;  31,  muscle. 


364  Nek  vo  us   Sys  tem. 

fibre  be  cut  across — say,  in  the  spinal  cord  —  the 
health  of  the  cortical  nerve  cell,  of  which  it  is  a 
process,  becomes  secondarily  impaired. 

We  have  spoken  of  the  motor  path  as  consisting 
of  an  upper  neuron  (the  cortical  cell  and  its  motor 
fibre)  and  a  lower  neuron  (the  anterior  cornual  cell 
and  its  motor  fibre).  It  must  be  realised  that  these 
are  not  entirely  independent  of  one  another.  On  the 
contrary,  tlie  upper  neuron  seems  to  exercise  a  sort  of 
restraining  influence  on  the  lower  which  checks  the 
outflow  of  nerve  energy  which  is  constantly  proceeding 
from  the  lower  neuron  to  the  muscles,  and  which 
produces  the  "  tone  "  of  the  latter.  The  result  of 
this  is,  that  if  the  upper  neuron  suffers  damage  in 
any  of  its  parts,  the  restraint  on  the  lower  neuron  is 
diminished,  the  tone  of  the  muscles  is  raised,  and,  as  a 
consequence,  what  are  known  as  the  "tendon  reflexes" 
of  the  muscles  become  exaggerated  {see  p.  434).  Tlie 
influence  which  the  lower  neurons  exert  on  muscles 
in  maintaining  their  tone  is  sometimes  spoken  of  as  a 
"  trophic  "  influence.  Thus,  if  the  lower  neuron  be 
injured  in  any  part  {e.g.  if  there  be  inflammation  of 
the  grey  matter  of  the  anterior  corn  11,  or  if  a  motor 
nerve  be  cut  across)  the  corresponding  muscle  fibres 
lose  their  "  tone,"  they  become  flabby  and  atrophied, 
and  are  then  said  to  be  "  degenerated." 

The  course  of  the  sensory  fibres  has  not  yet 
been  definitely  made  out.  The  fibres  for  touch  and 
muscular  sense  seem  to  run  in  the  posterior  columns, 
those  for  temperature  and  pain  in  the  grey  matter 
around  the  central  canal  (Ferrier)  or  in  the  antero- 
lateral tract  (Gowers).  The  fibres  of  the  posterior 
columns  end  in  the  nucleus  gracilis  and  nucleus 
cuneatus  of  the  medulla.  Up  to  this  point  the  neurons 
concerned  have  been  the  cells  of  the  posterior  root 
ganglia,  which  are  therefore  said  to  be  "  trophic  "  for 
the  s(  nsory  fibres  from  the  periphery  up  to  the  medulla. 


The  Spinal  Cord.  365 

Tliere  a  new  set  of  neurons  begins  with  the  cells 
of  the  nucleus  gracilis  and  nucleus  cuneatus.  The 
fibres  arising  from  these  cross  to  the  opposite  side  in 
the  lo^ver  pait  of  tlie  medulla,  forming  the  decussation 
of  the  tillet,  that  being  apparently  the  main  sensory 
crossing.  They  then  pass  up  to  tlie  tegmentum,  and 
the  majority  en  1  in  the  thalamus.  The  remainder, 
however,  appear  to  pass  up  through  the  posterior  part 
of  the  posterior  limb  of  the  internal  capsule  to  find 
their  termination  in  the  cerebral  cortex.  The  central 
convolutions,  and  especially  the  gyrus  fornicatus, 
seem  to  be  the  parts  of  the  cortex  chiefly  concerned 
in  the  appreciation  of  sensory  impressions,  but  it  is 
probable  that  the  sense  of  touch  is  located  in  the 
Rolandic  area  as  well.  The  muscular  sense  seems  to 
be  located  in  the  deeper  layers  of  the  motor  cortex. 
The  course  of  the  fibres  and  the  position  of  the  centres 
for  the  special  senses  are  described  under  the  section 
dealing  with  the  cranial  nerves.  The  speech  centres 
and  their  connections  are  described  at  p.  382. 

(2)  The  spioal  cord. 

The  cord  extends  as  far  down  as  the  interspace 
between  the  first  and  second  lumbar  spines;  the 
membranes  are  continued  down  as  far  as  the  body  of 
the  second  sacral  vertebra. 

The  cervical  enlargement  reaches  to  the  seventh 
cervical  spine.  Its  largest  part  is  opposite  the  disc 
between  the  fifth  and  sixth  cervical  vertebrae. 

The  lunibar  enlargement  lies  opposite  the  three 
lowest  dorsal  spines,  its  widest  part  corresponding  to 
the  body  of  the  twelfth  dorsal  vertebra. 

Physiologically  tlie  cord  is  to  be  regarded  as  made 
up  of  a  series  of  superimposed  segments,  from  eacli 
of  which  a  pair  oi  nerve  roots  arises.  To  enable  us  to 
localise  focal  lesions  of  the  cord  it  is  necessary  to  be 
acquainted  with  the  functions  of  each  segment,  and 
therefore  with  the  area  of  supply  of  the  pair  of  nerve 


C.  I. 

JI. 

Til. 
IV. 

V, 

VI. 
VII. 

VIII. 

1).  I. 

II. 

III. 

IV. 

V. 

VI. 

VII. 

VIII. 

IX. 

X. 

XI. 

XII. 

L.  I. 

II. 
III. 

IV. 
V. 


S.I. 

II. 
III. 

IV. 


OUIOIN    FllOAf   COIID. 


(1)  ,4  s  regards  bodies. 

Between  atlas  and 

occiput. 
Oiiiiuh-ile  axifi. 


Oiiposite  axis. 

Oiiposite  Srd  eerv, 
vert. 


Opposite  -4111  cerv, 
vert. 


Opposite  .ith  cerv. 

vert. 


Opposite  6tli  cerv. 
vert. 


Opposite  7th  cerv. 
vert. 

Opposite  disc  Ije- 
tween  7tb  cerv. 
and  1st  dorsal. 

Opposite  disc  be- 
tween 1st  and 
2udD. 

Opposite  disc  be- 
tween 2nd  and 
3rd  D. 

Opposite  disc  be- 
tween Srd  and 
4th  D. 

Opposite  lower 
border  4th  D. 

Opposite  lower 
border  5th  D. 

Oiiposite  body  of 
6th  D. 

Opposite  body  of 
7th  D. 

Opposite  body  of 
8th  D. 

Opposite  liody  of 
9th  D. 

Opposite  body  of 
10th  D. 

Opposite  ))0dy  of 
11th  D. 

Opposite  body  of 
12th  D. 

Opposite  body  of 
12th  D. 

Oppo.'-ite  body  of 
12th  D. 

Opposite  disc  be- 
tween 12th  D.  and 
1st  L. 

Opposite  Tiody  of 
1st  L. 


Opposite   body    of 
1st  L. 


(2)  As  regards  spines. 

A  hove  arch  of  atlas. 

Opiiosite     arch     of 
atlas. 

Opiiosite    siiiiie    of 

axis. 
Oiiposite      interval 

between  2nd  and 

."Jrd  spines. 

Opposite   spine    of 
Srd  cerv. 


Opposite   spine    of 
4th  cerv. 


Opposite    spine    of 
5th  cerv. 


Opposite   spine    of 

6th  cerv. 
Opposite    spine   of 

6th  cerv. 

Opposite    spine    of 
7th  cerv. 

Opposite   spine    of 
1st  D. 

Opposite   spine    of 
2nd  D. 

Opposite    spine   of 

Srd  D. 
Opposite    spine   of 

4th  D. 
Opposite    spine    of 

5th  D. 
Opposite    spine    of 

6th  D. 
Opposite    spine    of 

7th  D. 
Opposite    spine    of 

Hth  D. 
Opposite    spine    of 

9th  D. 
Opi)osite    spine    of 

loth  I). 

Opposite    spine    of 
nth  D. 


(Opposite    spine    of 
12th  D. 


POT  XT   OP  KXIT. 


Between  atlas  and 

occiput. 
Above  axis. 


Aliovc  .^rd  cerv. 
Above  4th  cerv. 


AV)ove  5tli  cerv. 


Above  6th  cerv. 


Above  7th  cerv. 


Above  Ist  dorsal. 
Between  island  2nd. 

Between  2nd  and  .3rd. 

Between  Srd  and  4th. 

Between  4th  and  5th. 


Between 
Between 
Between 
Between 

Between 

loth. 
Between 

nth. 
Between 

12th. 
Between 

1st  L. 
/Between 

L.    . 
Between 

L. 
Between 

L. 
Between 

L. 

Between 

\    1st  S. 


5th  and  6th. 
6th  and  7th. 
7th  and  8tb. 
8th  and  9th. 
"Jth  and 
10th  and 
nth  and 
12th  D.  and 
1st  and  2nd 
2nd  and  Srd 
Srd  and  4th 
4th  and  5th 

5th  L.  and 


f)p]>ositc   spine    of 
1st  L. 


Between  1st  and  2nd 

R. 
Between  2nd  and  Srd 

S. 


Between  .Srd  and  4ih 

S. 
Between  4th  and  5th 
k    S. 


C.  I. 

Jl. 
111. 

IV. 


VJ. 
Vll. 

VIII. 
D.  I. 

II. 

IJI. 

IV. 

y. 

Vf. 
VII. 

V^III. 

IX. 

X. 

XI. 

XII. 

L.  I. 

II. 
III. 
IV. 

V. 


.S.  I. 

II. 
III. 

IV. 
V. 


WU.sci.ics. 


Slonio  iiia.st(>icl.| 

'l'r;i])i'y,ius. 

Sc.Hlciii. 

llotalors  of  Ucud. 

Diapliragin. 

Diaiibragin,  supra  ami  infra  spiua- 
tiis,  deltoid,  biceps,  supinator 
loiigus,  coraco-bracbialis,  rbom- 
boids. 

Deltoid,  biceps,  sup.  longus  and 
brevis,  coraco-ljracblalis,  rbom- 
boids,  bracbialis-aiiticus,  teres 
minor,  pectoraJis  (clavic-bead), 
serratu.s  magnus. 

Biceps,  l)racliialis  anticus,  pector- 
alis  (clavic-head),  serratusmag- 
nus,  triceps,  extensors  of  wrist 
and  fingers,  pronat  )rs. 

Triceps,  extensors  of  wrist  and 
fingers,  pronators,  flexors  of 
wrist,  subscapularis,  pector- 
alis  (costal  bead),  latissimus 
dorsi,  teres  major. 

Flexors  of  wrist  and  fingers,  small 
muscles  of  band. 

Extensors  of  tbunib,  muscles  of 
tbenar  and  bypotbenar  emin- 
ences. 


'  Muscles  of  back  and  abdomen. 


Muscles  of  abdomen. 

Ilio-psoas,  sartorius,  quadriceps, 

adductors. 
Quadriceps,  internal  rotators  and 

abductors  of  hip. 
Abductors  and  adductors  of  hip. 

tibialis  anticus,  hamstrings. 

External  rotators  of  hip,  anterior 
tiliial  muscles,  extensors  of  toes, 
calf  muscles  and  glutei,  ham- 
strings. 


.Glutei,  calf  muscles,  peronei,  small 
)    muscles  of  foot. 


I  Perineal  muscles,  bladder  and  rec- 
/    turn. 


,  Back  of  bead,  angle 
of  j-iw  to  vertex, 
neck. 

Nock,  upper  shoul- 
der, u|iper  ]iari 
of  chest. 

Back  of  shoulder 
and  arm,  outer 
side  of  arm  and 
forearm. 

Narrow    strip     on 

front  and  back  of 

arm  and  forearm, 

outer  half  of  hand. 

Inner      side      and 

l)ack  of  arm  and 

forearm,    middle 

of  hand. 

Part  of  arm&fo rearm, 
inner  half  of  hand. 
Inner  side  of  arm 
and     forearm 
down  to  waist, 


ItKKI.KXKS. 


/Skin  of  chest  and 
abdo]ue.n  in 
bands  cor  r  e- 
sponding  to  dis- 
tribution of 

N    spinal  nerves. 


Skin  over  groin  and 

front  of  scrotum. 

Outer  side  of  thigh. 

Front  and  inner 
side  of  thigh. 

Inner  and  outer 
side  of  thigh  and 
leg  to  ankle. 

Back  of  Dhigh  (ex- 
cept in  distribu- 
tion of  1st  and  3rd 
sacral),  outer  side 
of  leg  and  foot. 

strip  on  back  of 
thigh  and  leg, 
sole  of  foot. 

Skin  over  sacrum, 
perineum,  gen- 
itals (posterior 
surface!,  rectum, 
and  vagina. 


Supinator. 

jerk, 
l)iceps 

jerk. 

Elbow 
jerk, 
wrist  jerk. 


Epigastric  (4th  to 
7th). 


Abdominal  (8th  to 
)    inh). 


Cremasteric. 


Knee  jerk. 


Gluteal. 


Plantar,        ankle 
>    jerk,  and  ankle 
clonus. 


Rectal 
/       vesical. 


and 


368 


Ner  vo  us   Svs  tem. 


roots  arising  from  it.  Tlie  table  on  pp.  366  and  367 
shows  (1)  The  points  of  origin  of  the  nerve  roots  from 
the  cord  as  regards  both  tne  bodies  and  the  spines  of 
the  vertebrae.  This  enables  one  to  localise  on  the  sur- 
face of  the  body  the  position  of  each  spinal  segment. 
(2)  The  points  of  emergence  of  the  nerve  roots  from 
the  spinal  canal ;  and  (3)  The  motor,  sensory,  and 
reflex  functions  of  each  pair  of  roots,  and,  therefore, 
of  each  segment. 

Plates  VI.  and  VII.  exhibit  in  a  diagrammatic 
form  the  motor  functions  of  the  cervical  and  lumbar 
segments ;  the  sensory  functions  are  shown  in  Figs. 
107  and  108. 


Fig.  107.  -  Lateral  view -of  the  skin  areas  supplied  by  tlie  second,  third, 
and  fourth  cervical  segments. 


5TERN0MAST01D 
S  C ALEN 1 
NECK     MUSCLES 
C  2and37"'''^'^  PE21US  (dovjn  to  6^"  dorsal) 


-^ 


o 


4 


T. 


'^.    ^ 


T^RES  MINOR     '^  ^6-  ^>     //) 


C0RAC0BRACHI/\LI5^'C> 


'^. 


'oy 


^     <. 


^A 


DE|P  SHOULDER  MUSCLES      \ 

e 


%. 


'^>.  r 


Vi 


^^ 


^      'V?,      V         /  ELBOW  JERK 
^•-v^       IWRrST  JERK 


^-o. 


V  I 


P^TO  RALIS  MAJOR  <^/      '^J*    ^A>   ^f/<t^ 

fTISSIMUS   DORSI      ^S 
ERESNVAJOR       A 


F 

L 

T  E^S  0  RS  o  F  T  H  UMB'-^<?', 

NlU'SCLES    OF  THENARF 

MO  H  V  POTH  EN  AR     jr 
EMINENCES  E, 

X — 


PLATE    VI.- MOTOR    SEGMENTAL    FUNCTIONS    OF     THE     CERVICAL 

ENLARGEMENT. 


\Toface'p.  369 


The  Spinal  Cord. 


369 


Fig.  108. — Sensory  segmental  functions  of  the  spinal  cord.    {Compiled  from 

variov^  sources  hy  J.  Purves  Stewart.) 


Fig.  109  shows  the  position  of  the  different 
tracts  of  the  cord  on  transverse  section. 

Tlie  following  list  shows  the  nerve  supply  of 
the  muscles  of  the  trunk  and  limbs.  It  may  be 
found  convenient  for  reference  in  the  study  of  cases 
of  periplieral  paralysis.  The  supply  of  the  head  is 
considered  along  with  the  cranial  nerves. 


370 


Ner  vo  us    Sys  tem. 


UPPER   LIMB. 


Post-Thoracic 
Suprascapular 


.     Serratus  uiagnus. 

/Supra-syinatus. 
I.  Int'ra-spinatus. 


(  Pectoralis  major 
Ex.  ANT.  THORACtC  J  (Upp.  part,  Low. 
IxT.  AST.  Thoracic. ^     part). 

».Pect()ralis  iniuor. 


^Coraco-brachialis. 

Mttsculo-cutane-       '§''^^P^-,- 
QQg  ,  Brachialis      anti- 

L    cus. 


Subscapular.. 


Circumflex 


MUSCULO-SPIRAL 


fSuhscapulari^. 
..  V  Teres  major. 
ILatiss.  dorsi. 

/Deltoid. 
••\Teres  minor. 


I  Triceps. 
)  Ext.      carp 


rad. 
Supinator  long. 


POST-lKTEROSSKUS  .( 


Supinator  l^revis. 

Kxt.     carp.      rad. 
brev. 

Ext.  carp.  idu. 

Ext.  comni.  digit. 

Ext.  ossis  me'tac. 
poll. 

Ext.  primi.  intern, 
poll. 

Ext.    seciind.    in- 
tern, poll. 

Ext.  indicis. 

Ext.  minimi 
digiti. 


I  Pronator  radii 
)     teres. 

Median C  Palmaris  lougus. 

I  Opponenspollicis. 
•^  Abductor  pollicis. 


/      all 

MEDIAN'  AND   ULNARS   pipy^v 

(jointly)  '^^^^"'^ 


^Flexor  lougns 

pollicis. 
I  Flexor  carpi  radi- 

sublim. 


Ulnar 


digit. 
Flexor  brevis  pol- 
^    licis. 

/"Flexor  carpi     nl- 
I     naris. 

J  Adductor  pollicis. 
"1  Muscles   of  little 
I     finger. 
l^Interossei.  ' 


TRUNK  AND  LOWER    MJIU. 


INTBRCOS'IALS 


Int'  rcostals. 
Rectus  abdominis. 
External  obliqne. 


Branches 
Lumbar 
Nerves 


OF  (  Erector  spina;. 
^.    yuadratus        I 
..  I      borum. 


Genito-crural.     Cremaster. 


Anterior 

('RURAL 


Sartorius. 
Pcctiueus. 
liectus  fL-moi'Is. 
Vastus  externus. 
Vastus  internus. 
,  Crureus. 


/  Gracilis. 

J  .\dductor  longus. 
Obturator     ••(  Adductor  brevis. 
I  Adductor    maguus 
^     Cwitli  sciatic). 

Small  Sciatic  .     Gluteus  raaximus. 

_  ("(iluteus  mediu.s. 

SUP.  Gluteal..  I  Tens.  vag.  fsmoris. 


Gre.vt  Sciatic 


fBicei: 
I  Semi 
,    f  Semi 

\ 


Int.  Popliteal- 


Plantar  s 


psfemoris. 
tendinosus. 
Semimembran- 
osus. 
Adductor  magnus 
(with  obturator). 

'Gastrocnemius. 
Soleus. 

Til)ialis  posticus. 
Flex,  comni.  digit. 
Flex.    long,   hallu- 
cis. 

Flex.   brev.  ballu- 

cis. 
Flex.  brev.  digit. 
Abductor  halluci.s. 
Adductor  hallucis. 
Ext.  I)revis.  digit. 
Interussei. 


r  Tibialis  anticus. 
I  Ext.    proi).    hallu- 

EXT.  POI'LITEAL-' 


'^  Ext.  digit,  iongiis 
\^Pcroncus  brevis. 


•^>^ 


"^ 


(/ 


-«,       /U  ^  OF   HIP. 


PLATE    VII.— MOTOR     SEGMENTAL    FUNCTIONS    OF    THE     LUMBAR 

ENLARGEMENT. 

[To  face  p.  371. 


The  Spinal   Cord. 


371 


The  peripheral  distribution  of  the  chief  sensory 
nerves  is  sulficiently  indicated  in  Figs.  110,  111, 
and  112.  The  exact  distribution  of  the  sensory  nerves 


Fig.  109. — Sclieme  of  a  transverse  section  of  the  spinal  cord,  slio^^lng  on 
the  left  side  the  positions  of  the  various  tracts,  and  on  the  right  side 
the' names  of  the  diseases  affecting  each  part. 

1,  Descending  flbres  of  fillet  in  lateral  ground  bundle ;  2,  Schultze's  descending 
tract  in  postero-external  tract ;  3  Septomarginal  tract  of  Bruce  and  Muir  in 
postero-intemal  tract.  Besides  tue  names  given  on  the  diagram, the  follow- 
ing synonyms  should  be  noted  :—Poscero-internal  tract  =  Fasciculus 
gracilis  =  Column  of  GoU  ;  Postero-external  tract  =  Fasciculus  cuneatus  = 
Column  of  Burdach ;  Marginal  zone  =  Lissauer"s  tract;  "Comma"  tract  = 
Ascending  antero-lateral  tract  =  tract  of  Gowers.  (This  must  not  be  con- 
fused with  Schultze's  descending  tract,  to  which  the  term  comma  tract  is 
also  sometimes  applied.) 

of  the  fingers  is  shown  in  Fig.  113,  and  should  be 
compared  with  the  segmental  sensory  distribution 
represented  in  Fig.  114. 

Vascular  supply  of  the  brain  and  spinal 


372 


Nervous  System. 


—r^ 


4l    7 


Fig.  110. — Cutaneous  nerve  supply  of  upper  limb. 
Anterior  aspect :  1,  cervical  plexus ;  2,  circumflex ;  3,  ext.  cut.  of  muse,  spiral ;  4, 
ext.  cutaneous ;  5,  mediau  ;  6,  ulnar ;  7,  int.  cutaneoiis ;  8,  nerve  of  Wrisberg ; 
Posterior  aspect :  1,  cervical  plexus;  2,  circumflex ;  S,  int.  cut.  of  muse, 
spiral;  4,  intercosto-hunieral ;  5,  nerve  of  Wrisberg;  6,  int.  cutaneous;  7, 
ext.  cut.  of  muse,  spiral  ;  8,  ext.  cutaneous;  9,  ulnar  ;  10,  radial. 


\2  ! 


?,. 


8 


10 


i    / 


o  / 


i"\    8 


Fig.  111.— Cutaneous  nerve  supply  of  lower  limb. 
Anterior  aspect:  1,  ilio-inguinal ;  2,  genito-cvural ;  3,  ext.  cutaneous;  4,  middle 
cutaneous  ;  5,  internal  cutaneous  ;  6,  patellar  plexus  ;  7.  brauclies  of  external 
popliteal;  S,  incernal  saphenous;  9,  musculo-cutaneotis ;  10,  external  sa- 
phenous; 11.  anterior  tibial.  Posterior  aspect:  1,  -',  3,  small  sciatic;  4,  ex- 
ternal cutaneous  ;  5,  internal  cutaneous;  6,  internal  saphenous;  7,  branches 
of  external  popliteal;  8,  short  saphenous  ;  9.  posterior  tilnal ;  10,  internal 
saphenous  ;  11,  internal  plantar ;  li',  external  plantar. 


374 


Nervous   System. 


cord. — The  brain  is  supplied  by  the  internal  carotid 
and  vertebral  arteries.  Owing  to  the  position  of 
origin  of  the  left  common  carotid,  an  embolus  can 
enter  it  more  easily  than  it  can  the  artery  of  the 
opposite  side.      Embolic  lesions  are   therefore  more 


Great  occipital  — -/— 


Small  occipital 
(cervical  plexus) 


Great  auricular 
(cervical  plexus) 


5th,  supra-orbital  branch 
5th.  auriculo  temporal  branch 

i [ — -J-Sth.  infra-orbital  branch 


Fis;.  112.- 


— -) 5th.  inferior  dental  branch 


Superficial  cervical 
(cervical  plexus) 


-Distribution  of  the  sensory  nerves  of  the  head.     Compare  witli 
it  the  segmental  distribution  as  shown  in  Fig.  lOS. 


frequent  in  the  left  than  in  the  right  cerebral  hemi- 
sphere. 

The  two  vei'tetoi'al  arteries  unite  at  the  lower 
border  of  the  pons  to  form  the  basilar,  which  runs 
up  the  middle  of  the  anterior  surface  of  the  pons,  and 
ends  by  di\dding  into  the  two  posterior  cerebrals.  It 
gives  off  lateral  branches  which  run  out  transversely 
over  the  pons,  and  vertical  branches  which  pass  into 
its  substance.  The  latter  not  infrequently  become 
thrombosed. 

The  posterior  cerebrals  supply  the  occipital 
lobes,  the  lower  part  of  the  tenqjorosphenoidal  lobes, 
with  the  uncinate  gyrus,  the  inner  part  of  the  crus 


Blood  Supply  of  Brain. 


375 


and  the  corpora  quadrigeraina,  and  tlie  posterior  part 
of  the  posterior  limb  of  the  internal  capsule.  Block- 
ing of  one  of  these  arteries  will  therefore  involve  the 
visual  centi'e  and  the  sensory  fibres. 

The  basilar  artery  supplies  the   upper  surface  of 


Fig.  113. — Showing  the  exact  distribution  of  the  sensory  nerves  of  the 

fingers. 

E,  radial ;  m,  median  ;  u,  ulnar. 


the  cerebellum  ;  the  vertebrals  supply  its  lower 
surface. 

The  iiiteriial  carotid  oives  off  the  anterior 

cerebral  artery,  which  curves  round  the  anterior 
end.  of  the  corpus  callosum,  and  is  chiefly  distributed 
to  the  inner  surface  of  the  cerebral  hemisphere  as  far 


376 


Ner  vo  us   Sys  tem. 


back  as  the  })arieto-occipital  fissure.      It  also  sup[)lies 
the  superior  frontal  convolution. 

The  internal  carotid  is  practically  continued  on  to 
the  brain  as  the  middle  cerebral,  which  lies  in  the 


p^ 


Sylvian  fissure.  An  embolus  which  has  found  its 
way  into  the  internal  carotid,  therefore,  usually  ends 
in  the  middle  cerebral  or  one  of  its  branches.  The 
middle  cerebral  gives  off  cortical  hrancltes^  which 
supply  the  nio^or  area  of  the  upper  part  of  the 
temporosphenoidal  lobe.      These  branches  anastomose 


Blood  Supply  of  Brain.  377 

freely  wifcli  those  of  adjoining  arteries,  hence  blocking 
of  one  of  them  may  be  largely  compensated  for  by 
the  establishment  of  a  collateral  circulation.  It  also 
gives  off  central  branches,  which  run  more  or  less 
vertically  upwards,  penetrating  into  the  brain  sub- 
stance and  supplying  the  basal  ganglia.  There  are 
two  chief  groups  of  these  central  arteries — an 
anterior  group  called  the  lenticulo-striate,  and  a 
posterior  group,  the  lenticido-optic.  These  arteries 
are  very  commonly  the  seat  of  miliary  aneurysms,  and 
as  the  lenticulo-striate  are  more  directly  exposed  to 
the  force  of  the  wave  of  arterial  blood,  they  are 
more  frequently  ruptured  than  are  the  lenticulo-optic. 
These  central  arteries  do  not  anastomose  with  one 
another.  They  are,  therefore,  to  be  regarded  as  end- 
arteries.  Hence  it  is  that  a  lesion  of  one  of  them  is 
much  less  likely  to  be  compensated  than  is  a  lesion  of 
a  cortical  branch. 

The  venous  blood  from  the  brain  is  poured  into 
the  venous  sinuses.  Owing  to  the  slow  current  in 
these,  thrombosis  readily  occurs  in  them.  The  blood 
from  the  interior  of  the  lateral  ventricles  is  chiefly 
returned  by  the  veins  of  Galen,  which  end  in  the 
straight  sinus.  Owing  to  their  long  course,  these 
veins  are  frequently  exposed  to  pressure  by  tumours, 
etc.  This  is  apt  to  lead  to  increased  exudation  of 
fluid  into  the  lateral  ventricles. 

The  arteries  which  supply  the  spinal  cord 
have  a  long  and  tortuous  course.  This  renders  them 
liable  to  thrombosis,  but  makes  embolism  of  them 
almost  impossible.  The  lower  end  of  the  cord  is  far 
removed  from  the  point  of  origin  of  the  vessels  which 
supply  it.  Hence  it  is,  perhaps,  that  this  part  is  more 
liable  to  suffer  damage  from  nutritional  changes  than 
are  the  higher  regions. 

The    student   mav  now    pass    to    the    method    of 


3  7  8  Ner  vo  us   Sys  tem. 

examining  a  patient  with  nervous  disease  as  described 
in  the  subsequent  sections.  We  would  recommend 
him  to  begin  by  ascertaining  the  state  of  the 
intellectual  faculties  of  the  patient,  including  speech 
(Section  II.).  He  should  then  rapidly  test  the  condition 
of  the  cranial  nerves  in  their  order.  How  this  is  to 
be  done  is  described  in  Section  III.  (p.  387).  By 
proceeding  thus,  valuable  information  is  gained  at  the 
outset,  which  may  guide  one  in  his  subsequent  in- 
vestigations. The  motor,  sensory,  and  reflex  functions 
should  then  be  examined  in  order,  following  the 
methods  described  in  Sections  IV.  (p.  418),  Y.  (p.  427), 
YI.  (p.  431).  Lastly,  the  electrical  reactions  of  the 
muscles  and  nerves  should  be  tested  in  those  cases  in 
which  it  may  seem  necessary  (Section  YII.,  p.  440). 

SECTION  II.— INTELLECTUAL   FUNCTIONS. 

It  is  important  to  arrive  at  some  idea  of  the 
patient's  intellectual  state  early  in  the  taking  of  a 
nervous  case,  as  it  affords  indications  that  are  of 
help  in  the  subsequent  investigation  of  his  symptoms. 
For  example^  if  one  finds  that  his  memory  is  deficient 
one  attaches  only  a  limited  value  to  the  account  that 
he  gives  of  the  onset  of  his  illness  or  the  state  of  his 
previous  health.  Or  if  one  discovers  that  he  is  coma- 
tose, or  unable  to  understand  speech,  it  is  evident 
that  one  cannot  expect  to  make  much  of  any  attempt 
to  investigate  the  state  of  his  sensory  functions. 
This  section  will,  therefore,  be  devoted  to  methods  of 
investigating  a  patient's  mental  condition,  including 
the  functions  concerned  in  producing  and  interpreting 
speech. 

The  first  thing  to  be  determined  is  whether  we  are 
dealing  with  a  riglit-liaiided  or  a  left-liaiicled 
patient.  The  importance  of  this  depends  upon  the 
fact  that  right-handed  people  are  left-brained,  and 
vice  versa.     Ask  the  patient,  if  a  male,  which  hand  he 


Intellectual  Functions.  379 

uses  to  throw  a  stone  or  to  pull  a  cork  :  if  a  female, 
which  haud  is  employed  in  comljing  the  hair.  It  is  of 
comparatively  little  use  to  ask  which  hand  he  writes 
with,  as  all  children  are  taught  to  write  with  the 
right  hand. 

The  state  of  the  iiieiiiory  next  calls  for  in- 
vestigation. It  may  be  tested  by  asking  the  patient 
what  day  of  the  week  it  is,  what  he  ate  at  breakfast, 
and  so  on."^  Inquire  as  to  his  sleep,  and  whether  or 
not  he  is  troubled  with  dreams. 

Note  whether  or  not  he  is  more  emotional  than 
is  normal.  An  abnormal  emotional  state  is  evidenced 
by  the  patient's  bursting  into  laughter  or  into  tears 
on  very  slight  provocation,  or  by  his  giving  way 
easily  to  fits  of  anger. 

In  the  course  of  taking  his  case,  one  will  already 
have  arrived  at  a  general  notion  of  the  degree  of  the 
patient's  intelligence.  Sometimes  it  is  necessary  to 
ascertain  whether  he  is  the  subject  of  Iialliicinatioiis 
or  delusions.  A  hallucination  consists  essentially 
in  an  imaginary  or  a  misinterpreted  sense  impression. 
A  delusion  is  purely  intellectual.  It  is  an  erroneous 
idea  which  would  be  incredible  to  the  patient's  equals, 
and  which  is  unshaken  by  facts.  If  the  patient  says 
he  hears  voices  when  no  one  is  present,  or  if  he  sees 
a  tree  and  believes  it  to  be  a  man,  he  is  the  subject  of 
a  hallucination — in  the  former  case  auditory,  in  the 
latter  visual.  If  he  declares  that  he  is  the  Emperor 
of  Russia,  he  is  the  victim  of  a  delusion.  The  existence 
of  hallucinations  and  delusions  is  often  difficult  to 
ascertain.  Sometimes  they  are  discovered  by  chance ; 
in  other  cases  they  can  be  elicited  by  skilful  question- 
ing :  often  they  are  reported  by  the  friends. 

Delirium  or  coma  may  be   present ;  in  such 

*  It  is  important  to  distinguish  between  («)  the  memory  of 
recent  events  and  [h)  the  memory  of  older  occurrences.  Both 
should  be  tested  in  eveiy  case. 


3^0  N'er  vo  us   S\  's  tem. 

a  case  the  investigation  of  the  intellectual  faculties 
already  described  is  futile. 

Lastly,  one  should  inquire  whether  or  not  the 
patient  is  the  subject  of  fits.  If  he  be  so,  a  full 
history  of  the  attacks  should  be  obtained,  following 
the  scheme  of  interrogation  given  on  p.  10.  Should 
the  observer  be  fortunate  enough  to  see  the  patient 
during  a  fit,  the  following  are  the  points  to  which 
he  should  specially  devote  attention  : — 

(1)  The  nature  of  the  movements. — Are  they 
general,  or  confined  to  one  limb  or  part  of  a  limb  ? 
Where  do  they  begin]  Are  the  convulsions  tonic 
or  clonic]  Is  there  any  struggling,  arching  of  the 
back,  or  attitudinising  ]  Are  the  abdominal  muscles 
involved  or  not  ] 

(2)  Is  there  any  involuntary  evacuation  of  the 
bladder  or  rectum  ] 

(3)  The  state  of  the  eyes.  —  Is  the  conjunctival 
reflex  present,  or  is  it  abolished  1  Do  the  pupils  react 
to  light  ]  Is  there  any  inco-ordinate  movement  of 
the  eyeballs  1 

One  should  next  proceed  to  the  investigation  of 
the  speech  functions.'^ 

Supposing  that  the  patient  is  able  to  speak,  one 
should  note  whether  there  is  any  peculiarity  in  his 
articulation.  The  following  are  the  chief  abnorm- 
alities which  may  be  present  : — 

(1)  Stammering:.— This  requires  no  special 
description. 

(2)  Lialling*,  or  baby  speech.  Ask  the  patient  to 
read  something  aloud.  If  he  lalls,  one  will  recognise 
that  all  the  difficult  consonants  are  dropped ;  he 
speaks  like  a  baby,  and,  if  a  child,  may  perhaps  make 
use   of  words  of  his   own  invention.     P,  B,  and  M, 

*  In  our  description  of  the  methods  of  clinically  investigating  the 
sjieech  functions  we  have  followed  very  closely  the  teaching  of  Dr. 
AVyllie  {;vide  his  valuable  work  on  the  "Disorders  of  Speech  "). 


Speech  Functions.  381 

T,  D,  and  N,  are  the  easiest  consonants ;  K,  G,  S, 
Sh,  and  Ch,  are  more  difficult ;  C  and  L  are  the 
most  difficult  of  all.  Thus,  such  a  patient  has  no  diffi- 
culty in  saying  "papa,"  "mamma";  but  if  asked  to  say 
"  British  constitution,"  he  will  probably  pronounce 
it  "  Bitte  tontitu." 

(3)  Scanning:    or    staccato    speech.  —  The 

patient  speaks  slowly  and  deliberately,  syllable  by 
syllable,  as  if  scanning  a  line  of  poetry.  Ask  him  to 
say  "artillery."  He  will  pronounce  it  "ar-til-ler-y." 
This  is  the  kind  of  speech  found  in  cases  of  multiple 
cerebro-spinal  sclerosis. 

(4)  Slurring-  speech. — The  syllables  are  slurred 
together  as  in  a  state  of  intoxication.  Thus,  "British 
constitution  "  becomes  "  Brizh  conshishushon."  This 
kind  of  speech  is  met  with  very  typically  in  general 
paralysis  of  the  insane. 

(.5)  Syllable-stwnibling-. — In  this  condition  the 
patient  misplaces  some  of  the  letters  in  a  word,  and 
reiterates  some  particular  syllables.  Thus  "West 
Eegister  Street"  becomes  "West  Eegigistrerer 
Street." 

If  the  patient's  defect  consists  not  in  any  per- 
version of  articulation,  but  in  an  inability  to  produce 
speech  at  all,  or  to  understand  it  when  spoken  or 
when  written,  then  his  condition  is  described  as  one 
of  aphasia. 

In  order  to  understand  the  method  of  investigating 
a  case  of  aphasia,  it  must  be  remembered  that  for 
purposes  of  speech  we  hav^e  (1)  a  producing  mechanism. 
This  consists  of  two  parts — one  concerned  in  the  pro- 
duction of  spoken  speech,  the  other  in  the  production 
of  written  speech.  (2)  A  receiving  mechanism.  ^  This 
also  consists  of  two  parts — one  for  the  reception  of 
spoken  speech,  the  other  for  t^he  reception  of  written 
speech. 


382  Ner  vo  us   Sys  tej\i. 

We  may  thus  classify  cases  of  aphasia  as  follows : — 

[  Aphomia  (loss  of  power 

1.  Lesions  of  productive  mechanism  1  of  talking). 

(motor  aphasia).  \  Agraphia  (loss  of  power 

(  of  writing), 

„    -r     •  J!  i-  \,     •       i  Auditory     (word     deaf- 

2.  Lesions  01  receptive  mechanism  \  -^  ness'i 

(sensory  aphasia).  \  ^.^^^^  (word  blindness). 


It  must  be  borne  in  mind,  however,  that  it  is  the 
exception  to  meet  with  a  case  of  aphasia  of  a  pure 
type.  Thus,  a  patient  may  have  both  aphemia  and 
also  word-deafness.  He  may  be  unable  to  read  as 
well  as  unable  to  write,  and  so  on. 

The  cortical  centres  for  the  production  and  re- 
ception of  speech  are  situated  in  the  left  cerebral 
hemisphere  in  right-handed  persons,  in  the  right 
hemisphere  in  the  case  of  those  who  are  left- 
handed.  Hence  the  importance  of  ascertaining  early 
in  the  investigation  of  a  nervous  case  whether  the 
patient  is  right-  or  left-handed. 

The  centre  for  sj)oken  speech  occupies  the  posterior 
extremity  of  the  third  frontal  convolution  (Broca's 
convolution),  and  the  lower  end  of  the  ascending 
frontal  and  probably  also  of  the  ascending  parietal 
convolution. 

The  centre  for  the  production  of  written  speech  is 
believed  to  be  in  the  posterior  end  of  the  second 
frontal  convolution. 


References  to  Fig.  115. 

c,  cuneus  ;  c  c,  posterior  extremity  of  corpus  callosnni;  F  ."5,  Broca's  convolution 
(speech  centre);  T  1,  suuerior  teniporo  sphenuidai,  or  Wernicke's,  convolu- 
tion (auditory  word  centi'C) ;  1  and  l',left  and  right  optic  radiations;  2,  fibres 
connectin?,'  Teft  angular  gyrus  with  left  cuneus  and  through  the  corpus 
callosum  (ii' and  2")  with  the  right  cuneus;  a  lesion  at  x  cuts  these  fil  ires  as 
well  as  the  optic  radiation,  and  therefore  causes  right  lateral  homonymous 
hemianopsia— word  blindness— but  no  agraphia  ;  3,  fibres  connecting  angular 
gyrus  with  Wernicke's  convolution.  The  straight  black  line  (4)  represents 
the  connection  between  Broca's  and  Wernicke  s  convolutions  ;  the  l^lack 
line  bifurcating  in  front  i5)  represents  the  connections  of  the  angular  gj'rus 
with  the  motor  region  of  the  left  (5')  and  right  (5")  hemispheres. 


Speech  Functions. 


383 


\Q.Qyr, 


Fig.  115. — Sch  ematic  figure,  showing  the  course  of  the  optic  fibres.     (From 

Wyllie,  after  Bejerine.) 

[For  references  see  foot  of  i>.  382.] 


384  Nervous  System. 

The  centie  for  the  reception  of  spoken  speech  is 
in  the  posterior  half  of  the  superior  teiiiporo-sphen- 
oidal  convolution,  and  that  for  the  reception  of  written 
speech  (visual  speech  centi-e)  in  the  angular  gyrus. 

The  visual  speech  centre  is  connected  by  special 
fibres  with  the  primary  visual  centre  in  each  occipital 
lobe.  Hence,  a  lesion  in  the  left  occipital  lobe  does 
not  produce  word-blindness  unless  it  be  so  situated  as 
to  cut  od  also  the  fibres  which  connect  the  visual 
centre  in  the  light  occipital  lobe  with  the  left  angular 
gyrus  (Fig.  115). 

For  practical  purposes  it  is  best  to  proceed  with 
the  investigation  of  any  case  of  aphasia  in  the  fol- 
lowing order  : — 

I.  ISpoken  speech. 

1.  How  is  it  received  and  interpreted  1 — Find  out, 
firstly,  whether  the  patient's  hearing  is  good.  If  so 
ask  him  to  put  out  his  tongue,  shut  his  eyes,  etc. 
If  he  does  so,  test  him  as  to  his  understanding  of 
nouns  by  asking  him  to  touch  his  nose,  ear,  chin, 
forehead,  etc.,  in  turn.  Then  test  his  verbs  by 
asking  him  to  smile,  to  whistle,  etc.  If  the  patient 
responds  satisfactorily  to  these  questions,  he  has  evi- 
dently no  difficulty  in  interpreting  the  meaning  of 
words  heard — i.e.  there  is  no  ivord-deafyiess. 

2.  How  is  it  j)roduce  I.  ? 

(1)  If  the  patient  can  only  use  a  few  words,  make 
a  note  of  what  these  are.  If  he  repeats  any  word  or 
phrase  again  and  again  ("recurring-  iitteraiice"), 
note  what  it  is. 

(2)  If  he  has  a  considerable  vocabulary,  make  a 
note  (rt)  of  any  examples  of  lalling,  slurring,  etc.,  as 
described  on  pp.  380  and  381.  This  affords  an  indi- 
cation of  his  j)oiver  of  articulation. 

Test  him  with  such  words  and  ])hrases  as  "British 
constitution,"  "  West  Register  Street,''  "  Biblical 
criticism,"  "artillery." 


Speech  Functions,  385 

{b)  Show  liini  common  ol)jects — a  knife,  a  pen,  a 
matchbox,  etc. — and  ask  him  to  name  them  or,  if  he 
is  dumb,  to  indicate  with  his  fincjers  the  number  of 
sylhibles  in  the  name  of  each.  If  he  is  unable  to 
fulfil  these  tests,  he  has  evidently  got  some  forget- 
f ulness  of  words  (aiiiiie§>ia.  verbalis).  Sometimes 
the  patient  has  a  general  idea  of  the  word  he  wants 
to  use,  but  forgets  exactly  how  to  pronounce  it. 
He  omits  some  syllables,  or  substitutes  others  for 
them,  so  that  the  listener  may  hardly  be  able  to 
make  out  what  word  it  is  he  wishes  to  use. 
This  has  been  termed  by  Wyllie  '■'■  articulative 
amnesia.'^ 

(c)  If  he  makes  mistakes  in  his  use  of  words, 
calling  the  knife  a  pen,  or  vice  versa,  he  is  suffering 
from  paraphasia.  In  that  case,  one  should  note 
whether  or  not  the  patient  shows  that  he  is  aware  of 
his  error  by  trying  to  correct  himself,  or  whether  he 
goes  on  talking  gibberish. 

3.  Hoiv  is  it  repeated  or  echoed  i — ^Ask  him  to 
repeat  words  after  you.  If  he  is  word-deaf,  try  to 
make  clear  your  request  by  the  aid  of  pantomime, 
repeating  the  word  or  phrase  over  and  over  again. 
If  he  is  able  to  repeat  what  you  say,  endeavour  to 
find  out  whether  or  not  he  understands  what  he  is 
saying. 

11.  l^%^i*itfeii  speech. 

1.  How  is  it  received  or  interpreted] — ^ Ascertain 
whether  or  not  his  sight  is  good.  If  so,  write  on  a 
piece  of  paper  such  questions  or  commands  as.  How 
old  are  you  ?  Put  out  your  tongue,  etc.  If  he  does 
not  respond  satisfactorily,  there  is  evidently  some 
word-blindness  present — i.e.  the  patient  has  visual 
aphasia, 

2.  Hoiv  is  it  iwodiiced  J — Ask  him  to  write  his 
name,  (This  can  often  be  done  when  all  other  power 
of  writing  is  lost.)     If  he  is  able  to  do  so,  ask  him 

z 


386  Nervous  System. 

some  simple  question — e.g.  How  many  do  two  and 
two  make  1 — and  got  him  to  write  a  reply.  If  he  has 
word-deafness,  put  your  question  in  writing.  If  his 
right  hand  is  paralysed,  make  him  write  or  print  with 
his  left.  If  he  writes  pretty  well,  get  him  to  write 
an  account  of  his  illness,  and  note  whether  he  makes 
use  of  the  wrong  word  at  times  (paragraphia),  or 
whether  there  is  repeated  use  of  any  particular 
word. 

3,  Can  he  write  to  dictation  or  copy  1 — Try,  using 
some  simple  book.  If  he  succeeds,  endeavour  to  ascer- 
tain whether  or  not  he  understands  the  meaning  of 
what  he  writes. 

III.  Plieiiomeiia  associated  avUIi  speech. 

1 .  Does  he  understand  'pantomime  ?  Does  he  nod 
his  head  for  "  yes,"  shake  it  for  "  no,"  and  can  he 
indicate  numbers  with  his  fingers'?  Loss  of  gesture 
language  is  termed  ainiiiiia.  Mistakes  in  the  use 
of  gestures — e.g.  nodding  for  "  no,"  or  shaking  the 
head  for  "  yes  " — is  termed  paramiiiiia. 

2.  Does  he  understand  symbols — e.g.  numerals  ? 
Thus,  one  may  write  down — - 

2  2  2 

2  2  2 

4  5  6 

and   ask   him  to  point  out  which  is  right.     If   he  can 
read  music,  test  him  with  musical  notes. 

3.  Can  he  recognise  common  objects  ? — Place 
beside  him  a  pencil,  a  coin,  and  a  match.  Ask  him 
to  strike  a  light,  or  to  write  something  down.  If  he 
is  unable  to  select  the  proper  article  for  the  purpose, 
he  is  suffering  from  mind -blindness.  Inability 
to  recognise  his  friends  is  another  proof  of  the  same 
condition. 


Olfactory  Nerve.  387 

SECTION    III.— CRANIAL   NEUVE 
FCTNOTIONS. 

In  this  section  we  propose  to  give  a  brief  resume 
of  the  essential  points  in  the  anatomy  of  each  cranial 
nerve,  to  indicate  its  functions,  and,  in  some  cases, 
the  chief  symptoms  which  result  from  its  paralysis, 
and  then  to  describe  the  method  in  which  one  inves- 
tigates the  state  of  the  nerve  at  the  bedside. 

First  ov  olfactory  iierve. 

Anatomy. — The  nerve  fibres  which  arise  from  the  olfactory 
bulb  are  distributed  to  the  Scbneiderian  membrane,  at  the 
upper  part  of  the  nasal  fossaa.  The  cortical  centre  for  smell  is 
believed  to  lie  in  the  uncinate  gyrus.  The  exact  course  of  the 
fibres  between  the  cortex  and  the  bulb  is  unknown,  but  it  is 
probable  that  some  of  them  do  not  decussate. 

Test. — Have  three  small  bottles  containing  some 
oil  of  cloves,  some  oil  of  peppermint,  and  some  tincture 
of  asafoetida.  Apply  these  to  each  nostril  separately, 
and  ask  the  patient  if  he  recognises  them.  In  test- 
ing, avoid  the  use  of  such  irritating  substances  as 
ammonia,  for  these  act,  partly  at  least,  through  the  fifth 
nerve.  The  sense  of  smell  may  be  abolished.  This 
is  known  as  anosmia.  Before  concluding  that  the 
nerve  is  at  fault,  take  care  to  exclude  local  changes 
in  the  nose  itself — e.g.  catarrh.  Parosmia  is  the 
name  applied  to  a  condition  in  which  the  sense  of 
smell  is  perverted,  so  that,  for  instance,  offensive 
substances  seem  to  have  a  pleasant  odour,  and  vice 
versd. 

Inquire  also  regarding  hallucinations  of  smell. 
These  sometimes  constitute  the  aura  of  an  epileptic 
fit. 

Second  or  optic  nerve. 

Anatomy. — From  the  retina,  which  is  the  end-organ  of  the 
sense  of  sight,  the  fibres  of  the  optic  nerve  pass  back  to  the 
optic  chiasma.      Here  the  fibres  from  the    inner  half  of  each 


388  Nervous   System. 

retina  decussate,  whilst  those  from  the  outer  half  remain  on 
the  same  side.  Each  optic  tract,  therefore,  consists  of  fihres 
from  the  outer  half  of  the  retina  on  the  same  side  and  the 
inner  lialf  of  the  retina  on  the  opposite  side.  Each  tract 
passes  back  to  the  corpora  quadrigomina,  thence  the  fibres 
pass  to  the  external  geniculate  body  of  the  same  side,  then 
reach  the  posterior  limb  of  the  internal  capsule,  on  leaving 
which  they  spread  out  in  the  optic  radiation  to  the  cortex 
around  the  calcarine  lissure.  This,  therefore,  constitutes  the 
primary  visual  centre,  and  represents  the  opposite  half  of  the 
field  of  vision,  the  left  halt'  of  the  held  of  vision  being  repre- 
sented in  the  cortex  of  the  right  hemisphere,  and  rice  versa. 
From  the  primary  visual  centre  fibres  pass  to  the  angular  and 
supramarginal  gyri  of  the  same  side,  and  these  constitute  a 
higher  visual  centre.  In  this  higher  centre  word  images  would 
appear  to  be  stored,  and  in  it  also  both  ej-es  would  seem  to  be 
represented,  but  the  field  of  the  opposite  eye  to  a  much  greater 
extent  than  that  on  the  same  side  (Fig.  115), 

Test. — In  testing  the  optic  nerve,  one  lias  to 
investigate  three  functions  :  (1)  Acuity  of  vision;  (2) 
extent  of  field  of  vision  ;  (3)  colour  sense.  We  shall 
consider  the  methods  of  testing  these  seriatim. 

Certain  preliminaries  must  always  be  attended 
to.  One  of  these  is  to  see  that  any  error  of  refraction 
in  the  patient's  eyes  is  first  corrected,  and  that  there 
is  no  opacity  of  his  media ;  another  is  to  take  care  to 
examine  each  eye  separately. 

1.  Acuity  of  vision. — If  this  be  very  much  di- 
minished, it  may  be  doubtful  whether  the  patient  is 
able  to  tell  light  from  darkness.  To  investigate  this, 
place  the  patient  in  a  darkened  room  opposite  to  a 
lamp,  alternately  cover  and  uncover  his  eye,  oi-, 
what  is  perhaps  a  better  plan,  concentrate  the  light 
upon  his  eye  by  means  of  a  mirror  or  lens,  and  ask 
him  to  say  when  it  is  light  and  when  dark. 

In  lesser  degrees  of  impairment,  ask  the  patient 
to  count  fingers.  This  is  done  by  placing  him  witli 
his  back  to  the  light  while  the  observer,  standing- 
facing  the  patient,  holds  up  a  varying  numV)er  of 
fingers   of   one    hand,   and   asks  .the    patient  to    say 


Optic  Nerve.  389 

how  many  there  are.  The  test  should  be  applied  at 
varying  distances. 

For  the  detection  of  slight  degrees  of  impairment 
of  visual  acuity  Snellen's  types  will  be  found  useful. 
These  consist  of  letters  of  different  sizes,  each  of 
which  should  be  capable  of  being  read  at  a  definite 
distance — the  largest  at  60  metres,  the  smallest  at 
6.  In  using  the  types,  the  patient  is  placed  with  his 
back  to  the  light,  while  the  types  are  placed  level 
with  the  eye  at  a  distance  of  6  metres  (about  20  ft.). 
He  is  then  asked  to  read  the  letters  from  above 
downwards.  For  the  purpose  of  recording  the  result, 
the  following  symbols  are  employed  : — 

V  =  visual  acuity. 

d  =  distance  of  eye  from  type  (i.e.  6  metres.) 
D  =        ,,  at  which  type  should  be  capable 

of  being  read. 

Suppose  that  at  6  metres  the  patient  is  able  to 

read  the   smallest   type — that  is  to  say,  that  which 

should  be  readable  at  6  metres  off.     Then  his  visual 

d  {i.e.  6  metres) 

acuity  (V)  =:    ^Fr~r- 1- 1 ^^  or  normal. 

•^  ^    '         JJ  (^.e.  0  metres) 

But   if   at  that    distance    he    can    only    read   the 

largest  size  of  type — that  which  one  should  be  able  to 

read  at  60  metres — then  Y  =    -— 

60. 

The    term     amblyopia     (literally    "blunt-eyed- 

ness  ")  is  often  used  to  mean  defective  vision   without 

any  visible  change  in  the  fundus  oculi,  or  with  signs 

of  mere  optic  atrophy.      By  crossed  amblyopia 

one  means  dimness  of  vision  in  one  eye,  there  being  a 
lesion  in  the  opposite  half  of  the  brain.  It  occurs, 
for  instance,  not  infrequently  in  hysterical  hemi- 
anaesthesia  on  the  same  side  as  the  loss  of  sensation. 
Tne  term  amaurosis  (literally  "  darkness")  used  to 
signify  complete  blindness  with  a  similar  absence  of 


390  Nervous   System. 

visible  change.  It  must  be  confessed,  however,  that 
these  terms  are  used  very  vaguely,  and  as  far  as 
possible  they  should  be  avoided. 

2.  Extent  of  field  of  vision. — For  ordinary 
clinical  purposes  the  extent  of  the  field  of  vision  can 
be  tested  with  sufficient  accuracy  in  the  following 
way  : — 

Seat  yourself  opposite  to  the  patient  and  at  a 
distance  of  about  half  a  yard  from  him.  If  his  right 
eye  is  to  be  tested,  ask  him  to  place  his  hand  upon  his 
left,  and  to  look  steadily  at  your  own  left  eye.  Look 
steadily  yourself  at  the  patient's  right  eye,  your  own 
right  being  closed,  and  hold  up  your  left  hand  in 
a  plane  midway  between  his  face  and  your  own, 
and  at  first  at  almost  full  arm's  length  off.  Keep 
moving  the  fingers  of  the  hand,  and  bring  it  nearer 
until  you  can  just  yourself  "  with  the  tail  of  your 
eye  "  catch  the  movement  of  the  fingers.  Then  ask 
the  patient  whether  he  sees  them,  telling  him  mean- 
while to  be  sure  not  to  take  his  own  eye  off  yours. 
If  he  fails  to  see  the  fingers,  keep  bringing  the  hand 
nearer  until  he  sees  them.  Test  the  field  in  this 
fashion  in  every  direction — upwards,  downwards,  to 
right,  and  to  left,  using  the  extent  of  your  own  field 
always  for  purposes  of  comparison. 

For  more  accurate  delimitation  of  the  field  of  vision, 
an  instrument  termed  the  perimeter  is  used.  For  a 
description  of  it  special  works  on  ophthalmology  must 
be  consulted. 

Changes  in  the  field  of  vision. — It  may  be  con- 
tracted all  round  its  periphery.  This  is  spoken  of  as 
"  concentric  diminution  "  of  the  field  of  vision.  It 
occurs  in  hysteria,  optic  atrophy,  and  various  aft'ec- 
tions  of  the  retina. 

Sometimes  the  loss  of  vision  is  confined  to  the 
centre  of  the  field.  This  is  spoken  of  as  a  central 
scotoma    or   as   central  amblyopia.     It   is  frequently 


Optic  Nerve.  391 

due  to  toxic  causes — e.g.  excess  in  tobacco  or  alcohol 
— causing  a  chronic  reti'obulbar  neuritis,  and  is  then 
generally  bilateral.  Sometimes  it  is  due  to  local 
disease  of  the  choroid  or  of  the  retina  in  the  neigh- 
bourhood of  the  macula.  In  that  case  it  may  afiect 
only  one  eye. 

The  term  Iieiiiiaiiopsia  (also  written  hemi- 
aiiopia  and  hemiopia)  means  loss  of  sight  in  one-half 
of  the  field  of  vision  in  both  eyes  from  causes  other 
than  disease  in  the  retina.  Right  lateral  hemi- 
anopsia means  abolition  of  the  right  half  of  the  field 
of  vision  ;  left  lateral  hemianopsia,  abolition  of  the 
left  half.  These  forms  of  hemianopsia  are  also  spoken 
of  as  "  homonymous.^^ 

"  Sujoe^'ior  "  and  "  inferior  "  hemianojjsia  mean 
loss  of  the  upper  and  lower  halves  of  the  visual  field 
respectively.  They  are  rarer  than  the  lateral  variety, 
and  are  sometimes  spoken  of  as  "  altitudinal " 
hemianopsia . 

Temporal  hemianopsia  means  loss  of  vision  in  the 
temporal  or  outer  halves  of  both  fields,  and  is  due, 
therefore,  to  loss  of  visual  power  in  the  nasal  half 
of  each  retina.  It  can  only  be  produced  by  a  lesion 
either  just  before  or  just  behind  the  optic  chiasma, 
involving  those  fibres  of  the  optic  nerves  which  have 
decussated,  and  is  accordingly  very  rare. 

Nasal  hemianopsia  signifies  a  loss  of  the  nasal 
or  inner  half  of  each  field,  and  indicates  a  diminution 
of  visual  power  in  the  temporal  side  of  each  retina. 
It  can  only  be  produced  by  a  bilateral  lesion  con- 
lined  to  the  uncrossed  optic  fibres  on  each  side  of  the 
chiasma.     It  only  occurs  with  excessive  raritj^. 

Temporal  and  nasal  hemianopsia  are  somebimes 
spoken  of  as  heteronymous y  in  contradistinction  to  the 
homonymous  variety. 

3.  CJoloiii'  sense. — This  is  tested  by  means  of 
Holmgren's  wools.     Throw  all  the  skeins  together  on 


362  Ner  vo  us   Svs  tem. 

a  table  in  good  daylight,  keeping  the  test  skein 
separate.  Explain  to  the  patient  that  he  is  to  match 
the  colour,  not  to  name  it,  and  that  he  is  to  select  all 
those  skeins  which  are  like  it,  whether  they  are  of 
a  darker  or  lighter  shade  or  not.  Show  him  first 
a  pure  pale  green  skein,  and  ask  him  to  match  it.  If 
he  does  so  correctly,  his  colour  vision  is  normal.  If, 
on  the  other  hand,  he  selects  one  of  the  "  con- 
fusion colours,"  (grey,  straw  colour,  etc.)  he  is  to 
be  regarded  as  colour-blind. 

Total  colour-blindness  is  rare.  Eed-green  blindness 
is  the  commonest  form.  Yellow-blue  Vjlindness  is  not 
nearly  so  conmiou.  If  the  patient  is  totally  colour- 
blind he  confuses  with  the  test  skein  all  those  of 
equal  brightness,  no  matter  what  their  tint  may 
be.  If  red-green  blindness  is  suspected,  show  him 
a  purple  skein  and  he  will  select  blue  as  a  match 
for  it — indicating  that  he  fails  to  see  the  red  element 
in  the  purple.  If  he  be  blue  blind  he  will  select  red 
or  orange. 

Colour  field. — In  a  normal  eye  the  field  for 
blue  is  largest,  then  comes  yellow,  then  red,  and  lastly 
green.  Concentric  diminution  of  the  colour  field 
occurs  in  hysterical  amblyopia.  In  some  toxic  con- 
ditions, especially  tobacco  poisoning,  one  finds  a 
central  scotoma  for  colour.  Its  existence  can  easily 
be  determined  by  placing  the  patient  with  his  back 
to  the  light,  and  then  holding  up  about  2  feet  in  front 
of  him  a  square  of  black  pasteboard  in  the  centre  of 
which  is  a  small  white  spot.  Ask  him  to  look  steadily 
at  the  white  spot,  and  while  he  does  so  suddenly  place 
about  2  inches  to  the  outer  side  of  the  spot  a  black 
strip  of  cardboard,  near  the  end  of  which  a  red  or 
green  wafer  has  been  fixed.  If  a  central  colour  sco- 
toma is  present,  the  patient  will  not  see  the  red,  or 
green  spot  whilst  he  is  looking  at  the  white  one.  If, 
on  the  other  hand,  the  coloured  spot  be  placed  to  the 


Third^  Fourth^  and  Sixth  Nerves.     393 

inner  side  of  the  ^vhite  spot,  he  lias  usually  no  diffi- 
culty in  seeing  it.  Colour-blindness,  of  course,  inter- 
feres with  the  use  of  the  test  in  some  cases. 

The  exact  extent  of  the  field  for  each  colour  is  best 
test-ed  by  means  of  the  perimeter. 

Subjective  visual  seusatious  mav  be  pre- 
sent. Amongst  the  commonest  of  these  for  which 
one  ma}^  have  to  inquire  is  the  occurrence  of  what 
are  known  as  muscc*^  volitantes — little  specks  or  moats 
seen  floating  before  the  eyes,  especially  on  looking  at 
a  white  surface  or  up  to  the  sky.  They  are  not  in- 
frequent in  antemic  and  debilitated  persons.  In 
migraine  peculiar  zig-zag  lines,  known  as  "  fortifica- 
tion fiirures,"  are  often  seen  at  the  beginning  of  the 
attack,  and  in  the  investigation  of  such  a  case  should 
always  be  inquired  for.  The  teruL  teicTiopaia  is  also 
applied  to  the  condition.  Hallucinations  of  sight 
occur  in  some  cases,  notaljly  in  delirium  tremens  ] 
they  may  also  form  part  of  the  aura  in  epilepsy. 

Third,  fouitli,  and  i^ixtli  nerves. — It  is  con- 
venient to  take  these  together,  as  conjointly  they 
serve  to  innervate  the  muscles  which  move  the  eye- 
baU. 

Anatomy. — The  fibres  of  these  nerves  take  their  origia  from 
a  series  of  nuclei  which  begin  in  the  floor  of  the  aqueduct  of 
Sylvius  below  the  anterior  corpora  quadrigeniina,  and  extend 
down  as  far  as  the  eminentia  teres  in  the  floor  of  the  fourth 
ventricle.  The  nucleus  for  the  third  nerve  is  highest  up.  Its 
most  anterior  cells  supply  the  ciliary  muscle  and  iris,  those 
for  the  ocular  muscles  being  farther  back.  Behind  that  comes 
the  nucleus  of  the  fourth,  and  most  posteriorly  of  all  that  of 
the  sixth.  The  third  nerve  emerges  on  the  inner  aspect  of 
the  crus,  and  is  therefore  apt  to  be  involved  in  lesions 
implicating  that  part  of  the  brain. 

The  foui'th  pair  emerge  on  the  anterior  part  of  the  roof  of 
the  fourth  ventricle.  They  are  peculiar  in  that  they  are  the 
only  cranial  nerves  which  decussate  between  their  nuclei  and 
their  point  of  emergence. 

The  sixth  emerges  between  the  medulla  and  pons,  and  runs 
forward  beneath  the  latter  for  a  considerable  distance  before 


394  -^-^^  '^<^  ^^     -^  ^^  TEM. 

leaving   tlie   slcull.     This  long  course  renders  it  particulculy 
liable  to  the  effects  of  pressure. 

Fiiiiclioiis. — The  sixth  nerve  supplies  the  ex- 
ternal rectus,  the  fourth  supplies  the  superior  oblique. 
All  the  other  ocular  muscles,  along  with  the  sphincter 
pupillte,  the  muscle  of  accommodation,  and  the  levator 
palpebrse  superioris,  are  supplied  by  the  third. 

Symptoiiis  of  paralysis. — SixtJi  nerve.  Ina- 
bility to  move  the  eye  outwards  and  diplopia  on  look- 
ing in  that  direction.  Possibly  internal  squint.  In 
nuclear  lesions  there  is  also  loss  of  the  power  of  con- 
jugate deviation  in  the  direction  of  the  affected  muscle. 

Fourth  nerve. — Impaired  power  of  downward 
movement ;  possibly  upward  and  inward  squint ;  and 
diplopia  on  looking  down. 

Third  nerve. — Ptosis ;  the  eye  can  only  be  moved 
outwards  and  a  little  downwards  and  inwards  ;  loss  of 
accommodation ;  pupil  of  medium  size  and  unable  to 
contract ;  loss  of  power  of  accommodation. 

Paralyses  of  the  third  nerve  are  not  infrequently 
partial — only  one  or  a  few  of  these  functions  being 
lost. 

Thus  the  levator  palpebrte  superioris  is  often 
alone  atfected,  producing  ptosis,  while  the  other 
muscles  retain  their  normal  power.  In  order  to 
estimate  the  degree  of  ptosis,  one  must  eliminate 
the  action  of  the  occipito-frontalis.  This  is  done  by 
pushing  down  upon  the  latter  muscle  so  that  the 
eyebrows  are  kept  level,  and  then  asking  the  patient 
to  look  up.  The  amount  to  which  the  lids  are  raised 
indicates  the  strength  of  the  levator. 

Any  retraction  of  tlie  upper  lid,  from  over- 
action  of  the  levator,  is  to  be  noted  by  observing  the 
relation  of  the  edge  of  the  lid  to  the  upper  margin  of 
the  cornea  when  the  patient  is  looking  straight  forward. 

How  to  test  tliese  nerves.  — •  As  will  be 
gathered  from  the  above  resume,  the  signs  of  a  lesion 


Squint.  395 

involving  any  of  these  nerves  may  be  :  (1)  The  pres- 
ence of  a  squint ;  (2)  defective  power  of  movement 
of  the  eye  ;  (3)  the  presence  of  diplopia.  Of  these 
signs  the  last  is  really  the  most  trustworthy  of  all,  for 
paralysis  of  the  muscles  supplied  by  the  nerve  may 
be  80  slight  as  to  lead  to  no  appieciable  squint  and  to 
no  visible  defect  in  mobility. 

We  shall  consider  the  question  of  squint  first. 

1.  By  squint  or  strabisiiiiis  is  meant  a  want 
of  parallelism  in  the  two  visual  axes.  It  may  be 
due  either  to  paralysis  of  a  muscle  or  to  over-action — ■ 
i.e.  spasm — of  its  opponent.  The  former  constitutes 
paralytic  strabisniiis,  the  other  brings  about  what 
is  called  "  concomitant "  (or  simsmodic)  strabis- 
nitis.  The  first  point,  therefore,  to  be  decided  about 
any  squint  is  this — Is  it  paralytic  or  is  it  concomitant  ^ 
The  chief  points  of  distinction  between  the  two  are 
these  : — 

{a)  Spasmodic  squint  is  always  present ;  on  asking 
the  patient  to  look  straight  forward,  which  is  the 
position  of  rest  of  all  the  ocular  muscles,  the  squint 
is  seen  at  once.  Paralytic  strabismus,  on  the  other 
hand,  may  only  be  visible  when  the  patient  happens 
to  look  in  a  direction  requiring  the  action  of  the 
paralysed  muscle. 

(6)  In  spasmodic  strabismus  the  affected  eye  follows 
the  sound  eye  equally  in  all  its  movements.  It  is  for 
this  reason  that  it  is  termed  "concomitant."  The 
visual  axes  are  not  parallel  even  in  the  position  of 
rest,  and  the  defect  of  parallelism  remains  the  same 
in  whatever  direction  the  patient  turns  his  eyes.  In 
paralytic  squint  the  visual  axes  may  appear  parallel 
in  the  position  of  rest,  but  even  if  they  do  not, 
the  Avant  of  parallelism  becomes  more  and  more 
evident  the  farther  the  patient  tries  to  turn  his 
eyes  in  the  direction  of  action  of  the  paralysed 
muscle. 


396  Ner  vo  us   Sys  tem. 

(c)  Diplopia  is  usually  present  in  paralytic  squints, 
absent  in  those  which  are  spasmodic. 

The  commonest  form  of  concomitant  squint  is  the 
internal  strabismus  which  occurs  in  children,  and  is 
associated  with  hypermetropia. 

2.  Defective  power  ol"  iiiovenieiit  of  the 
eye.— In  order  to  elicit  this  symptom,  place  the 
patient  with  his  back  to  the  light ;  stand  in  front  of 
him,  and,  holding  up  one  finger,  ask  him  to  follow  its 
movements  with  his  eyes.  It  will  easily  be  noticed 
whether  or  not  a  squint  is  brought  out  in  either  eye 
when  he  attempts  to  do  so.  The  examination  may  be 
repeated  on  each  eye  separately,  its  mobility  being 
tested  in  each  direction. 

The  power  of  convergence  of  the  eyes  should 
always  be  tested  in  addition  to  the  mobility  of  each 
eye  separately.  In  order  to  do  this,  hold  up  your 
finger  directly  in  front  of  the  patient  at  a  distance  of 
about  18  in.  from  the  tip  of  his  nose.  Tell  him 
to  keep  looking  at  the  finger,  which  is  then  gradually 
brought  nearer  to  the  nose.  Note  to  what  extent 
convergence  occurs,  and  whether  it  is  well  maintained 
■ — i.e.  whether  the  eyes  remain  directed  towards  each 
other  or  whether  they  diverge  again  after  their  first 
convergence. 

In  some  cases  the  defective  mobility  is  so  slight  as 
to  elude  detection.  This  is  especially  apt  to  be  the 
case  in  paralysis  of  the  oblique  muscles.  In  such  a 
case  one  falls  back  upon  the  diplopia  as  an  indication 
of  the  ajffected  muscle. 

3.  Diplopia. — In  order  to  elicit  this  symptom, 
hold  your  finger  straight  up  in  front  of  the  patient, 
and  ask  him  how  many  there  are.  Then  repeat  the 
question  with  the  finger  held  at  each  side  of  the 
visual  field,  then  high  up,  and  then  low  down.  Make 
sure  that  the  patient's  head  is  not  moved  during  the 
investigation.     If  in  each  position  he  sees  one  finger 


Diplopia.  397 

only,  there  is  no  diplopia.  If  at  any  part  of  the  field 
two  fingers  are  seen — one  distinct,  the  other  some- 
wliat  hazy — one  may  be  sure  that  diplopia  is  present. 

In  that  case  one  has  next  to  ascertain  (1)  whicli 
is  the  affected  eye ;  (2)  which  is  the  afiected  muscle 
in  that  eye. 

In  order  to  determine  these  points,  proceed  as 
follows : — 

Place  over  one  of  the  patient's  eyes  a  red  glass — 
preferably  over  the  stronger  eye,  if  he  has  better 
vision  in  one  than  the  other.  Then  hold  up  in  front 
of  him  a  tall  lighted  candle.  Move  it  about  until 
he  sees  two  candles — a  red  and  a  yellow.  One  of 
these  is  the  true  image — i.e.  that  of  the  sound  eye  ;  the 
other  is  the  false  image — i.e.  that  of  the  affected  eye. 
Which  is  which  ?  In  order  to  answer  this  question  the 
following  rule  is  given  : — 

The  affected  eye  is  that  in  the  direction  of  the  image 
of  tvhich  the  diplopia  increases. 

The  application  of  this  rule  will  be  made  plain  by 
an  example.  Suppose  the  red  glass  is  opposite  the 
patient's  left  eye,  and  the  patient  says  that  the  red 
image  is  to  the  right  of  the  yellow.  On  moving  the 
candle  farther  to  the  right  the  distance  between  the 
images  increases — i.e.  the  diplopia  becomes  greater — 
that  is  to  say,  it  becomes  greater  on  moving  the 
candle  in  the  direction  of  the  red  image.  But  that  is 
the  image  belonging  to  the  left  eye ;  therefore,  apply- 
ing the  rule,  the  left  eye  is  the  one  that  is  affected. 

The  affected  eye  having  been  thus  discovered,  one 
wishes  to  know  which  is  the  affected  muscle.  To  help 
one  in  this  a  second  rule  has  been  given  : — 

The  paralysed  muscle  is  that  lohich  would  have 
turned  the  eye  in  the  position  and  direction  oj  the  false 
image. 

In  the  above  example  one  found  that  the  left  eye 
was  the  one  afiected,  and  that  its  image  was  to  the 


398 


Ner  fo  us   Sy^s  tem. 


right  of  tho  true  image.  Applying  the  above  rule, 
one  asks,  Which  muscle  moves  the  left  eye  to  the 
right]  and  the  reply  is,  The  internal  rectus.  The  left 
internal  rectus,  therefore,  is  the  affected  muscle. 

When,  as  in  this  case,  the  false  image  is  on  the 
opposite  side  to  the  affected  eye,  the  diplopia  is  said 
to  be  ^^  crossecV ;  when  the  false  image  is  on  the  same 
side  as  the  affected  eye,  the  diplopia  is  said  to  be 
"  direct.^''       Paralysis    of    an    internal    rectus    always 

]3roduces  a  crossed 
diplopia  ;  paralysis 
of  an  external  rectus 
a  direct  diplopia. 

The  detection  of 
the  affected  muscle 
in  cases  of  ver- 
tical diplopia  is 
somewhat  more  dif- 
ficult than  in  cases 
where  the  diplopia 
is  lateral.  The  same 
rules,  however,  ap- 
ply. Suppose,  again, 
that  the  red  glass 
is  over  the  left 
eye,  and  that  two  images  are  seen,  one  above 
the  other,  the  yellow  being  higher  up.  On 
looking  upwards  the  distance  between  the  images 
becomes  greater ;  therefore,  according  to  the  first  rule, 
the  right  eye  is  the  one  affected.  Which  is  the 
paralysed  muscle  ?  In  order  to  apply  the  second  rule, 
one  must  remember  the  action  of  each  muscle,  and, 
from  the  position  of  the  false  image  as  described  by 
the  patient,  deduce  which  muscle  it  is  which  would 
have  turned  the  eye  in  that  position  and  direction. 
This  will  be  the  muscle  affected,  Werner's  diagrams 
(Figs.    116,    117)    facilitate    the    recollection  of   this 


Fig.  116. 


Diplopia. 


399 


greatly.  The  continuous  lines  on  the  diagrams  re- 
present the  positions  of  the  true  images,  the  dotted 
lines  those  of  the  false  images.  Thus  in  paralysis 
of  the  left  inferior  rectus  the  false  image  is  at  a 
lower  level  than  the  true,  it  is  to  the  right  side  of 
the  true  image  (crossed  diplopia),  and  its  upper  end 
is  inclined  towards  the  true  image  (Fig.  116).  In 
paralysis  of  the  left  inferior  oblique  the  false  image  is 
higher  up  than  the  true  image  and  to  its  left  side 
(direct  diplopia), 
and  its  upper  end 
is  inclined  away 
from  the  true 
image  (Fig.  117). 

To  return,  then, 
to  our  supposed 
case.  One  had 
proved  that  the 
right  eye  was  the 
one  affected,  and 
that  its  imao-e  was 
higher  up  than  the 
true  imao;e.  The 
paralysis  must 
therefore  affect 
either  the  right  superior  rectus  or  the  right  inferior 
oblique.  Ask  the  patient  whether  the  upper  end  of 
the  false  image  is  inclined  towards  or  away  from  the 
true,  and  whether  it  is  to  the  right  or  the  left  of  the 
latter.  Supposing  he  says  that  the  false  image 
(yellow  candle)  is  to  the  left  of  the  true,  and  with 
iis  upper  end  inclined  away  from  the  latter.  Then, 
one  knows  at  once,  by  referring  to  the  diagram 
(Fig.  116),  that  the  right  superior  rectus  is  the 
muscle  affected. 

If,  in  the  above  example,  the  patient  is  unable  to 
state  clearly  whether  the  false  image  is  to  the  right 


Left         !  V    HiCfUt 

Sap.  051.1  ^Su/j.OU 


Fig.  117. 


400  Nervous   System. 

or  left  of  the  true,  and  what  is  the  exact  nature 
of  its  inclination,  one  can  have  recourse  to  another 
method.  Ask  in  which  direction  the  difference  in 
height  of  the  two  images  increases.  If  towards 
the  temple,  the  rectus  is  the  affected  muscle.  If 
towards  the  nose,  it  is  the  oblique. 

In  applying  the  above  tests  it  is  more  convenient 
to  move  the  patient's  head  in  order  to  change  tlie 
direction  of  his  eyes  than  to  move  the  candle.  Thus 
if  one  turns  the  head  to  the  left  and  asks  him  to  look 
at  the  candle,  the  eyes  are  turned  to  the  right.  Thus 
moving  the  head  to  the  left  comes  to  the  same  thing 
as  moving  the  candle  to  the  right,  and  vice  versd. 
To  lower  the  eyes,  hold  the  head  back ;  to  elevate 
the  eyes,  depress  the  chin.  These  movements  are 
effected  by  the  observer,  who  places  himself  at  the 
patient's  side,  the  lighted  candle  being  placed  on 
a  table   some   distance  off. 

The  position  of  tlie  patient's  liea<1  is  also 
of  considerable  help  in  detecting  tlie  paralysed 
muscle.  He  tries,  by  turning  his  head,  to  give  to 
the  affected  eye  the  position  in  which  it  should  be 
placed  by  the  paralysed  muscle.  Thus,  if  the  face 
is  turned  to  the  left,  it  indicates  a  paralysis  of  the 
left  external  rectus  or  right  internal  rectus,  and  vice 
versd.  If  it  be  directed  upwards,  an  elevator  is 
paralysed  ;  if  downwards^  a  depressor.  If  the  head  is 
inclined  to  the  left  shoulder,  it  indicates  pai^alysis 
of  the  superior  rectus  or  oblique  of  the  right  eye, 
or  of  the  inferior  rectus  or  oblique  of  the  left  eye. 
If  the  inclination  of  the  head  is  towards  the  right 
shoulder,  it  indicates  paralysis  of  the  superior  rectus 
or  oblique  of  the  left  eye,  or  of  the  inferior  rectus  or 
oblique  of  the  right  eye. 

Abnormal  movements  of  the  eye. 

Involuntary  clonic  contractions  of  the  muscles  of 
the  eyeball  not  infrequently  occur.     The  movements 


IVys  ta  gm  us.  401 

are  usually  symmetrical,  occurring  equally  in  both 
eyes.  To  these  movements  the  term  nystagmus  is 
applied.  If  the  external  or  internal  recti  are  affected, 
lateral  nystagmus  results.  Vertical  nystagmus  is  due 
to  an  atfection  of  the  superior  or  inferior  recti,  and 
rotary  nystagiiius  to  an  involvement  of  the  oVjlique 
muscles.  Lateral  nystagmus  is  the  commonest 
variety. 

In  examining  for  nystagmus,  ask  the  patient 
to  look  straight  in  front  of  liim,  and  observe  whether 
the  eyes  remain  steady.  Then  ask  him  to  look  to  his 
extreme  right,  then  to  the  left,  and  then  upwards  and 
downwards.  Nystagmic  movements  are  frequently 
onl}^  to  be  observed  when  the  eyes  are  turned  as  far 
as  possible  in  one  of  these  directions.  Such  an 
occurrence  is  indicative  of  paresis  of  the  muscles 
which  turn  the  eyes  in  that  particular  direction. 

If  both  eyes  are  kept  persistently  turned  in  one 
direction,  the  condition  is  spoken  of  as  conjiig-ate 
deviation  of  the  eyes.  It  is  usually  either  to  the 
right  or  to  the  left.  Conjugate  deviation  of  the  eyes 
may  Vje  brought  about  either  by  a  lesion  which  produces 
paratysis  oi-  by  one  which  causes  irritation  or  spasm. 
In  the  former  case  the  eyes  (and  usually,  also,  the 
head)  are  turned  towards  the  side  of  the  lesion,  pro- 
vided the  latter  be  in  the  cerebral  hemisphere.  The 
patient,  in  fact,  is  said  "  to  look  towards  his  lesion." 
An  irritative  lesion  in  a  similar  situation  causes  the 
deviation  to  be  towards  the  healthy  side.  If,  how- 
ever, the  lesion  have  its  seat  in  the  pons,  these 
rules  are  just  reversed,  the  deviation  being  towards 
the  sound  side  in  a  paralytic  lesion,  and  towards  the 
affected  side  in  one  which  is  irritative. 

examination  of  the  pupils. — This  important 
part  of  the  investigation  of  a  nervous  case  may  be 
conveniently  considered  at  this  stage.  The  following 
points  must  be  noted  about  the  pupils  in  every  case  : — 

A  A 


402  Nervous  System. 

1.  ISize. — Compare  the  size  of  the  two  pupils, 
first  in  a  bright  light  and  then  in  a  dim  light.  Note 
whether  the  pupils  are  large  or  small,  and  whether 
any  irregularity  is  present.  It  must  be  remembered 
that  the  size  of  the  pupil  in  health  is  subject  to  great 
variations.  As  a  rule,  the  pupils  are  larger  in 
dark  eyes  than  in  light.  A  much  dilated  pupil  is 
often  a  sign  of  nervous  exhaustion  or  instability. 
Slight  inequality  of  the  pupils  may  also  be  present 
in  perfectly  healthy  subjects.  We  are  inclined  to 
think  that  in  such  cases  the  left  pupil  is  usually  the 
larger. 

If  one  pupil  is  larger  than  the  other,  the  question 
arises  :  Which  is  the  normal  %  This  question  is  not 
always  very  easily  answered,  but,  as  a  rule,  the  pupil 
which  exhibits  the  least  mobility  is  to  be  regarded  as 
the  abnormal  one. 

2.  Shape. — Note  whether  the  pupil  is  circular 
in  outline,  as  it  should  be,  or  whetlier  its  contour  is 
irregular.  Such  irregularities  may  be  due  to  adhesion 
of  the  iris  to  the  lens  {see  p.  454).  Irregularity  in 
shape  of  the  pupil  is  often  an  early  symptom  in 
general  paralysis  of  the  insane. 

^.  Mobility. 

{a)  Reaction  to  lig^ht. — This  is  a  reflex  action. 
The  stimulus  is  produced  by  the  action  of  light  on 
the  retina,  and  travels  along  the  optic  nerve  and 
optic  tract  to  the  corpora  quadrigemina,  and  thence 
by  communicating  tibres  (Meynert's  fibres)  to  the 
centre  for  the  third  nerve.  The  motor  impulse  passes 
from  that  centre  by  means  of  the  fibres  of  the  third 
nerve  to  the  sphincter  pupillae  muscle  (Fig.  118). 

Test. — Examine  each  e3^e  separately.  Place  the 
patient  opposite  a  bright  Hght,  and  cover  the  eye 
with  the  hand.  Leave  it  covered  for  about  half  a 
minute,  then  withdraw  the  hand  and  watch  the 
pupil.     It  should  contract  almost  immediately,  then 


The  Pupils. 


403 


dilate    again    a    little,    and,   after    undergoing    slight 
oscillations,  settle  down  to  its  normal  size. 

The  test  may  also  be  carried  out  by  concentrating 
light  upon  the  pupil  by  means  of  a  mirror  or  lens, 
just  as  one  does  in  testing  the  light  perception. 

Owing  to  the  decussation  of  some  of  the  fibres  of 
the  optic  nerves  at  the  chiasma,  light  acting  upon  one 
eye  affects  the  centre  for  pupil  contraction  of  the 
other  eye  as  well  as  that  on  its  own  side.  It  is 
probable  that  fibres  pass  directly  between  the  centres 
for  the  two  third 
nerves  which  aid 
in  bringing  about 
this  result.  As 
a  consequence, 
one  finds  tliat  if 
light  be  shut  off 
from  one  eye  both 
pupils  dilate,  and 
if  bright  light  be 
made  to  enter  one 
eye  both  pupils 
contract.  This  is 
known  as  the 
c  o  11  s  <^  11  s  II  a  I 
reaction  of  the 
pupils.  It  should 
be  tested  by  keep- 
ing one  eye  in  the 
shade  while  light 
is  thrown  into  the 
other.  The  effect 
on  the  jjupil  of 
the  shaded  eye  is  then  observed. 

Lesions  of  the  optic  nerve  or  optic  tract  interfere 
with  this  reflex. 

ITeriiiclse's  hemiopic  pupil  reaction  may 


Fig.  lis. — Diagram  showing  the  connections 
of  the  centres  for  contraction  of  the 
pupils.  (Svsanzy.) 
3  >.',  3  X,  centre;  1,  connection  between  nuclei  of 
3rd  nerves;  2,  Meynert's  fibres;  Q,  corpora 
quadrigemina ;  c,  chiasma ;  o,  optic  nerve  ;  p. 
pupil  contracting  fibres  of  3rd ;  l,  seat  of 
lesion  ;  arrows  shijw  path  of  impiUse  in  lesion 
of  right  tract  at  l. 


404  Nervous  System. 

be  mentioned  here.  Hemianopia,  as  we  have  seen, 
may  be  due  to  a  lesion  of  the  optic  tract  between  the 
chiasma  and  the  corpora  quadrigemina,  or  it  may  be 
produced  by  destruction  of  the  optic  fibres  between 
the  corpora  quadrigemina  and  the  occipital  cortex,  or 
it  may  be  due  to  lesions  in  the  cortical  visual  centres 
themselves. 

If  the  lesion  be  in  front  of  the  corpora 
quadrigemina — i.e.  in  front  of  the  pupil  centre — -the 
light  reflex  is  lost ;  whereas,  if  it  be  at  any  point 
behind  that  the  contraction  of  the  pupil  to  light  is 
retained.  It  is  uj)on  this  fact  that  Wernicke's  reaction 
is  based.  In  carrying  out  the  test  the  light  must,  of 
course,  be  concentrated  on  the  blind  halves  of  the 
retinse.  Proceed  as  follows :  Place  the  patient  in  a 
dark  room  with  a  light  beside  his  head.  Hold  a 
large  plane  mirror  in  the  left  hand,  and  by  means  of 
it  illuminate  both  pupils  and  observe  their  size.  Then 
take  an  ordinary  ophthalmoscopic  mirror  in  the  right 
hand  and  direct  a  strong  beam  of  light  on  to  the  blind 
side  of  the  retinse.  If  the  lesion  be  in  front  of  the 
corpora  quadrigemina  no  contraction  of  the  pupils 
should  result,  if  behind  that  they  become  smaller. 

(6)  Reaction  to  accoiiiiiiodation. 

As  is  well  known,  the  pupils  become  smaller  on 
accommodating  for  a  near  object.  It  is  really  more 
correct  to  speak  of  reaction  to  convergence.,  as  it  is 
found  that  it  is  the  convergence  of  the  eyes,  not  the 
mere  effort  of  accommodation,  which  causes  the  pupil 
to  become  smaller. 

Te6^^.— Hold  up  one  finger  close  to  the  patient's 
nose.  Ask  him  to  look  away  at  a  distant  object. 
Then  suddenly  tell  him  to  look  at  your  finger.  As 
the  eyes  converge  to  accomplish  this  the  pupils 
should  become  decidedly  smaller. 

If  the  patient  is  unable  to  see,  the  test  may  still 
be  carried  out  by  getting  him   to   hold  up  his  own 


The  Pupils.  405 

iinger   ahout   ca   foot   in   front   of    liis   face   and   then 
asking  him  to  direct  his  eyes  to  it. 

If  the  pupil  reacts  to  accommodation  but  iiot  t(» 
light,  it  is  probal)le  that  there  is  a  lesion  either  of  the 
optic  or  of  Meynert's  fibres.  If  it  reacts  neither  to 
light  nor  to  accommodation,  it  is  probable  that  there 
is  a  lesion  either  of  the  pupil  centre  or  of  tlie  fibres 
of  the  third  nerve. 

Argyll-Robei'tsoii  piipil.^ — This  is  the  term 
applied  to  the  condition  of  ptipil  tisually  observed  in 
locomotor  ataxy.  It  reacts,  to  accommodation  but  not 
to  light.  It  is  probably  due  to  a  lesion  in  Meynert's 
fibres  (Fig.  118) — i.e.  the  fibres  of  communication 
between  the  corpora  quadrigemina  and  the  ptipil 
centre. 

(c)  Cilio  -  f^piiial  reflex. — Dilatation  of  the 
pupil  can  often  be  observed  to  follow  irritation  of  the 
skin  of  the  neck  either  by  pinching  or  by  the  action 
of  a  Faradic  current.  It  is  due  to  stimulation  of 
the  pupil-dilating  fibres  in  the  cervical  sympathetic 
(p.  417),  and  is  abolished  in  lesions  of  that  nerve, 

Abiioriiial  iiioveiiieiits  of  the  pupil* 

Tlie  term  "  liippiis  "  is  applied  to  the  alternate 
contraction  and  dilatation  of  the  pupil  which  can 
sometimes  be  observed  going  on  rhvthmicallv  {see 
p.  454).  '  ^     ■ 

Fifth  nerve. 

Anatomy. — 1.  The  seilSOry  I'OOt  takes  origin  iu 
a  large  nucleus  in  the  pons,  situated  in  the  floor  of  the  fourth 
ventricle  and  lying  external  to  the  motor  nucleus,  and  partly 
also  from  the  "ascending"  root,  which  begins  as  low  down 
as  the  second  cer^^cal  segment.  It  emerges  at  the  side  of  the 
pons,  and,  immediately  beyond  the  Gasserian  ganglion,  separates 
into  its  thi'ee  divisions.* 

The  fii'«;t,  or  ophlhaliuic,  division  supphes 
the  eyeball,  conjunctiva  (except  that  of  the  lower  lid)  and 
lachrymal  gland,  the  mesial  part  of  the  skin  of  the  nose  as  far 
as  the  tip,  the  upper  eyelids,  the  forehead,  and  the  scalp  as  far 
as  the  vertex. 


4o6 


Nervous  System. 


Paralysis  of  this  division  results  in  loss  of  sensi- 
bility in  the  area  of  skin  and  mucous  membrane 
supplied,  and  in  trophic  changes  in  the  eyeball  (if  the 
lesions  involve  the  Gasserian  ganglion).  The  conjunc- 
tival reflex  is  abolished. 

The  second  or  superior  maxillary  division 

supplies  the  cheek,  the  front  of  the  temple,  the  lower  eyelid 
and  its  conjunctiva,  the  side  of  the  nose,  the  upper  lip,  the 
upper  teeth,  the  lining-  membrane  of  the  nose,  the  upper  part 
of  the  pharynx,  the  roof  of  the  mouth,  the  soft  palate,  and  the 
tonsils. 

Paralysis  of  it  leads  to  abolition  of  sensibility  in 

the  above  area,  and  loss  of  the  palate  reflex. 

The  third  or  inferior  maxillary  division  is 

joined  by  the  motor 
root.  It  suj)plies 
sensation  to  the 
lower  part  of  the 
face,  the  lower  lip, 
the  side  of  the  head, 
the  ear,  the  tongue, 
and  the  lower  teeth. 
It  supplies  also  the 
salivary  glands  and, 
through  the  motor 
division,  the  mus- 
cles of  mastication, 
the  tensor  tympani, 
and,  also  perhaps, 
the  tensor  palati, 
although  many  be- 
lieve that  this  mus- 
cle is  innervated 
spinal 


the 


Fig.  119. — Distribution  of  aiiftsthesia  in  comxilete 
paralysis  of  the  fifth  nerve. 


by 
cessory 

root. 

origin 


ac- 


Wlotor 

This  takes 
n    a   small 


nucleus  lying  internally  to  the  chief  sensory  nucleus,  and  partly 
also  from  the  descending  root,  which  arises  in  nerve  cells  scattered 
around  the  aqueduct  of  Sylvius.  It  emerges  at  the  side  of  the 
pons,  just  in  front  of  the  sensory  division,  passes  underneath 
the  Gasserian  ganglion,  and  joins  the  inferior  maxillary 
division,  to  which  it  gives  its  motor  fibres. 


Fifth  Nerve.  407 

Paralysis  of  the  whole  fifth  nerve  leads  to  loss  of 
sensation  in  the  areas  of  skin  and  mucous  membrane 
above  mentioned,  and  to  defective  power  of  chewing. 
(Fig.  119.)  Trophic  lesions  may  be  present,  and  the 
salivary,  buccal,  and  lachrymal  secretions  much 
diminished,  and  the  sense  of  taste  abolished. 

One  curious  result  of  the  sensory  paralysis  is  that 
the  patient,  when  drinking,  imagines  that  the  cup  is 
broken,  as  he  only  feels  it  on  one  side  of  his  mouth. 

How  to  test  the  fifth  nerve. 

1.  motor  fiiiietioiis. — Ask  the  patient  to  clench 
his  teeth  while  the  observer  keeps  his  hands  on  the 
temporal  and  then  on  the  masseter  muscles.  These 
should  stand  out  with  equal  prominence  on  each  side. 
If  there  be  paralysis  on  one  side,  the  muscles  on  that 
side  will  fail  to  become  prominent.  On  opening  the 
mouth  the  jaw  deviates  towards  the  paralysed  side, 
being  pushed  over  by  the  healthy  external  pterygoid 
muscles.  The  condition  of  the  tensor  tympani  muscle 
cannot  be  satisfactorily  examined  except  by  noting 
whether  there  is  any  difficulty  in  hearing  notes  of  a 
particular  pitch — i.e.  a  diminution  in  the  "  field  of 
hearing." 

2.  Sensory  functions. — The  common  sensi- 
bility o!  the  area  supplied  is  tested  in  the  usual  way 
(p.  42;;). 

Taste. — In  suspected  lesions  of  the  fifth  nerve 
the  sense  of  taste  should  always  be  examined.  It 
seems  probable  that  all  the  taste  fibres  eventually 
reach  the  brain  in  the  fifth  nerve.  The  taste  fibres 
from  the  anteiior  two-thirds  of  the  tongue  pass  from 
the  lingual  nerve  to  the  chorda  tympani,  thence  to  the 
facial,  thence  by  the  great  superficial  petrosal  to 
Meckel's  ganglion,  and  thence  to  the  second  division 
of  the  fifth. 

The  taste  fibres  from  the  posterior  third  of  the 
tongue  enter  the  glossopharyngeal  nerve,  leave  it  in 


4o8  Nervous  System. 

the  nerve  of  Jacobsoii,  reach  the  tympanic  plexus, 
and  thence  by  the  small  superficial  petrosal  and 
otic  ganglia  arrive  at  the  third  division  of  the  fifth. 

Once  the  taste  fibres  have  entered  the  brain  their 
exact  course  becomes  doubtful.  There  is  no  doubt 
that  they  reach  the  posterior  part  of  the  internal 
capsule,  and  by  that  time  they  have  already  decus- 
sated. It  is  probable  that  they  end  in  the  tip  of  the 
temporosphenoidal  lobe. 

How  to  test  the  sense  of  taste. — Have 
some  sugar,  some  quinine,  and  some  salt,  all  in 
powder.  Ask  the  patient  to  put  out  his  tongue  and 
to  keep  it  out  until  the  conclusion  of  the  test.  Place 
some  sugar  on  the  tongue,  rub  it  gently  in,  and  ask 
him,  "  Is  that  salt  %  "  If  taste  is  normal  he  will  shake 
his  head.  In  this  way  all  the  substances  are  tried, 
first  on  the  anterior  part  of  the  tongue  and  then  at 
the  back.  A  weak  galvanic  current  is  also  a  useful 
test.     It  should  produce  a  sort  of  metallic  taste. 

Loss  of  taste  may,  of  course,  arise  from  lesions 
of  the  taste  fibres  in  any  part  of  their  course  above 
stated. 

In  addition  to  loss  of  taste,  one  should  always 
ask  the  patient  whether  he  has  any  abnormal  taste 
sensations. 

Seventh  nerve. 

Anatomy. — The  course  of  the  fibres  of  this  nerve  from 
the  cortical  centre  to  the  nucleus  has  alreadj'  been  described 
(p.  360).  The  nucleus  is  situated  in  the  pons  external  to 
that  of  the  sixth  nerve.  The  fibres  which  are  destined  to 
supply  the  orbicularis  palpebrarum,  however,  possibly  proceed 
from  the  nucleus  of  the  third,  and  those  for  the  obicularis  oris 
from  that  of  the  twelfth  nerve.  On  leaving  the  nucleus  the 
fibres  wind  round  the  nucleus  of  the  sixth,  and  finally  emerge 
along  with  the  eighth  nerve,  between  the  olive  and  restiform 
bodies. 

The  nerve  lies  in  close  contact  with  the  eighth,  so  that  a 
lesion  of  the  one  at  this  part  can  hardly  avoid  injuring  the 
other,  and'  enters    the   internal    auditory  meatus  along  with 


Seventh  Nerve,  409 

it.  During  its  course  in  the  aqufduct  of  Fallopius  it  gives 
off  a  branch  to  the  Stapedius  muscle,  and  is  joined  b}'  the 
chorda  tympani,  which  contains  taste  fibres  from  the  anterior 
two-thirds  of  the  tongue.  In  this  part  of  its  course  the  nerve 
is  exposed  to  the  effects  of  pressure,  owing  to  its  being  en- 
closed in  a  bony  tube.  It  emerges  at  a  point  opposite  the 
junction  of  the  anterior  border  of  the  jnastoid  with  the  ear, 
and  spreads  out  on  the  side  of  the  face  to  supply  its  muscles. 
In  this  part  of  its  course  it  seems  to  be  peculiarly  liable  to 
the  effects  of  exposure  to  cold. 

Fiinctioii«i. — The  seventh  is  a  purely  motor 
nerve.  It  supplies  all  the  muscles  of  the  face  and 
scalp,  except  the  levator  palpebree  superioris.  It  also 
supplies  the  platysma. 

Effects  of  paralysis. — These  are  usually  at 
once  seen  on  looking  at  the  patient.  The  affected 
side  of  the  face  has  lost  its  expression.  The  naso- 
labial fold  is  less  pronounced  than  on  the  other  side. 
The  furrows  of  the  brow  are  smoothed  out,  the  eye 
is  more  widely  open  than  the  other,  and  the  mouth  is 
somewhat  drawn  to  the  healthy  side.  The  patient  is 
unable  to  whistle,  and  food  is  apt  to  collect  between 
his  teeth  and  his  gums. 

How  to  test  tlie  seventh  nerve. 

(1)  Ask  the  patient  to  shut  his  eyes  as  tightly  as 
ever  he  can.  Note  that  the  affected  eye  is  either  not 
closed  at  all — in  which  case  the  eyeball  rolls  upwards 
to  make  up  for  the  failure  of  the  lid  to  descend — or, 
if  the  eye  is  closed,  the  eyelashes  are  not  so  far  rolled 
in  as  on  the  healthy  side.  Try  also  forcibly  to  open 
the  eyes  while  the  patient  attempts  to  keep  them 
closed.  If  the  orbicularis  is  acting  normally,  it  should 
be  almost  impossiljle  to  open  the  eye  against  the 
patient's  wish.  If  the  muscle  be  partially  paralysed, 
however,  the  exertion  of  very  little  force  may  sutlice 
to  open  it. 

The  effort  made  in  screwing  the  eyes  tightly  shut 
causes  the  corners  of  the  uiouth  to  be  drawn  upwards. 
In  paralysis  of  the  lower  part  of  the  face  the  corner 


4IO  Nervous  System. 

on  the  affected  side  is  either  not  drawn  up  at  all,  or 
at  all  events  not  so  much  as  on  the  healthy  side. 

(2)  Ask  the  patient  to  whistle.  He  is  unable  to 
do  so. 

(3)  Ask  him  to  smile  or  to  show  his  upper  teeth. 
The  mouth  is  then  drawn  to  the  healthy  side. 

Sig^ns  of  paralysis  of  the  facial  nerve 
\i\  different  parts  of  its  course- 
Paralysis  of  the  seventh  nerve  produces  different 
symptoms  according  as  the  lesion  is  situated  above 
the  nucleus  or  either  at  the  nucleus  or  below  it.  The 
former  constitutes  what  is  known  as  cerebral  or  supra- 
nuclear facial  paralysis,  the  latter  produces  peripheral 
or  infranuclear  paralysis. 

The  chief  difference  between  the  two  forms  is  that 
in  supranuclear  paralysis  the  lower  part  of  the 
face  is  chiefly  affected;  in  peripheral  paralysis 
both  the  upper  and  lower  parts  are  equally  involved. 
The  probable  explanation  of  this  is  that  the  two  or- 
bicularis palpebrarum  muscles  are  so  often  required 
to  act  together  that  each  is  supplied  from  both  sides 
of  the  brain,  and  consequently  a  unilateral  lesion  oidy 
partially  cuts  off  the  nerve  impulses  to  one  side.  We 
have  already  described  what  is  meant  by  "  crossed 
paralysis,'^  and  the  part  which  the  facial  plays  in  it. 

Infranuclear  facial  paralysis  may  be  pro- 
duced by  a  lesion  of  the  nucleus  itself,  of  the  nerve 
trunk  inside  the  aqueduct,  or  of  the  nerve  trunk  either 
after  its  emergence  from  the  aqueduct  or  before  it  has 
entered  it. 

A  lesion  inside  the  aqueduct — unless  it  be  towards 
the  outer  end  of  the  latter — involves  the  fibres  of  the 
chorda  tympani,  and  therefore  produces  a  paralysis 
of  taste  sensation  in  the  anterior  two-thirds  of  the 
tongue.  A  lesion  in  any  of  the  other  situations 
produces  a  typical  complete  facial  paralysis  (Bell's 
paralysis). 


Eighth  Nerve.  411 

A  lesion  of  the  nerve  before  it  has  entered  the 
aqueduct  can  be  distinguished  from  a  lesion  below 
the  stylo -mastoid  foramen  by  the  fact  that  in  the 
former  condition  the  Stapedius  muscle  is  paralysed 
(causing  excessive  sensitiveness  to  loud  sounds  or 
"  hyperacusis  ")  while  in  the  latter  it  escapes.  Never 
omit,  therefore,  in  a  case  of  facial  paralysis  to  inquire 
regarding  the  patient's  sensitiveness  to  loud  sounds. 

The  practical  deduction  from  these  facts  is  that 
in  examining  a  case  of  facial  paralysis  one  should 
never  omit  to  investigate  the  taste  sensibility  of  the 
anterior  part  of  the  tongue. 

Abnormal  facial  niovemeiitis. — The  muscles 
supplied  by  the  facial  nerve  are  frequently  affected  by 
spasmodic  movements.  These  may  involve  all  the 
facial  muscles  or  groups  of  them  only.  The  spasm 
may  be  of  either  the  clonic  or  tonic  variety  (p.  425). 
The  nature  of  the  movements  if  present,  their  extent, 
and  the  muscles  affected  by  them  should  always  be 
carefully  noted. 

Eig:litli  IVerve  (auditory). 

Anatomy. — This  nerve  consists  of  two  sets  of  fibres.  One 
set  supplies  the  cochlea,  and  subserves  the  function  of  hearing ; 
the  other  part  supplies  the  vestibule  and  semicircular  canal, 
and  is  the  nerve  of  equilibration.  The  auditory  fibres  arise 
from  a  nucleus  which  is  mesially  placed  in  the  floor  of  the 
fourth  ventricle.  They  emerge  dorsally  to  the  restiform  body 
forming  the  dorsal  root  of  the  eighth  nerve.  The  fibres  for 
equilibration  take  origin  in  a  nucleus  placed  laterally  to  the 
other,  and  emerge  on  the  ventral  aspect  of  the  restiform  body 
forming  the  ventral  root  of  the  eighth  nerve.  The  two  roots 
join,  and  the  fibres  run  together  to  the  bottom  of  the  internal 
auditory  meatus,  where  they  separate,  to  be  distributed  to  the 
different  parts  of  the  inner  ear. 

The  cortical  centre  for  hearing  is  in  the  first  and  second 
temporosphenoidal  convolutions  of  the  opposite  hemisphere. 
The  exact  course  of  the  fibres  between  the  nucleus  and  the 
cortex  is  unknown. 

The  cortical  centre  for  the  fibres  of  equilibration  is 
probably  situated  in  the  cerebellum,  but  as  to  that  nothing  is 
definitely  known. 


41-2  Nervous  System. 

Test,  (a)  Hearing:. — Before  testing  a  patient's 
power  of  hearing  it  is  well  to  exclude  the  presence  of 
wax  in  the  ear  {see  p.  469).  This  being  disposed  of, 
one  can  test  the  hearing  power  b}^  means  of  a  watch. 
Stand  behind  the  patient  and  ask  him  to  shut  his  eyes. 
Begin  outside  the  probable  range  of  hearing  jDOwer 
and  bring  the  watch  gradually  nearer  the  ear,  asking 
the  patient  to  speak  whenever  he  hears  the  tick. 
One  requires,  of  course,  to  know  at  what  distance 
the  tick  should  be  audible  by  a  healthy  ear.  It  is 
well  to  test  each  ear  separately,  one  being  closed 
whilst  the  other  is  being  examined. 

If  impairment  of  hearing  be  detected,  one  must 
next  try  to  ascertain  whether  it  is  really  due  to 
disease  of  the  auditory  nerve  or  merely  to  some 
affection  of  the  middle  ear.  In  order  to  settle  this 
point,  the  timing:  forlt  test  may  be  employed. 
Strike  a  tuning  fork  and  place  the  end  of  it  against 
the  centre  of  the  patient's  forehead.  If  the  deafness 
discover-ed  by  the  watch  is  due  to  an  affection  of 
the  middle  ear,  the  patient  will  hear  the  tuning  fork 
louder  on  that  side  than  on  the  healthy  one.  On 
the  other  hand,  if  the  deafness  is  due  to  disease 
of  the  auditory  nerve  the  tuning  fork  will  only  be 
heard  on  the  healthy  side.  The  test  may  also  be 
carried  out  by  means  of  the  watch.  In  affections  of 
the  nerve,  the  watch  is  not  heard  even  when  pressed 
against  the  ear  ;  in  disease  of  the  middle  ear,  it  is 
heard  even  more  loudly  than  when  similarly  applied 
to  the  healthy  side.  The  explanation  of  these  facts 
is  not  yet  clearly  made  out,  nor  are  they  invariably 
trustworthy.  They  hold  good,  however,  for  a  majority 
of  cases.  Other  points  in  favour  of  the  deafness 
being  due  to  the  nerve  and  not  to  the  middle  ear  are, 
(a)  if  the  hearing  is  better  in  a  quiet  place,  (b)  if 
conversation  is  heai-d  better  than  the  watch,  (e)  if 
inflation  of  the  middle  ear  renders  the  li earing  worse. 


Eighth  N'erve.  413 

Abnormal       auditory      isciisatioii!^.  —  The 

patient  may  complain  of  "  ringing  in  the  ears  "  or 
tinnitus.  The  precise  character  of  the  sound  varies 
in  dillerent  cases.  It  may  be  of  a  humming,  buzzing, 
hammering,  or  whistling  character.  The  presence  or 
absence  of  this  symptom  should  always  be  inquired 
for,  and  Avhether  it  is  constantly  present  or  in  what 
circumstances  it  comes  on. 

Hyper^esthesia  of  the  auditory  nerve  (liyper- 
actisis),  by  which  even  slight  sounds  are  heard  with 
painful  intensity,  sometimes  occurs,  especially  in 
hysteria  and  in  lesions  of  the  facial  nerve  above  or 
in  the  aqueduct  owing  to  paralysis  of  the  stapedius 
muscle. 

Hallucinations  of  sound  may  also  be  present, 
the  patient  fanc^dng  that  he  hears  voices,  bells,  etc. 
The  presence  of  these  points  to  an  affection  of  the 
cerebral  cortex. 

(6)  .Equilibration. — This  sense  cannot  be  con- 
veniently tested  clinically.  Disorders  of  it  produce 
vertigo.  The  patient  will  describe  this  as  giddiness 
or  dizziness.  In  order  to  constitute  true  vertigo, 
external  objects  should  seem  to  move  round  him. 
Ask  if  this  is  so,  and,  if  it  is,  in  what  direction  the 
objects  seem  to  move.  Ask  also  whether  the  vertigo 
ever  causes  him  to  fall  to  the  ground. 

Vertigo  may  be  due  to  paralysis  of  one  of  the 
ocular  muscles,  to  an  aifection  of  the  ear  or  auditory 
nerve,  to  loss  of  muscular  or  common  sensibility 
especially  in  the  lower  extremities,  or  to  an  affection 
of  the  stomach.  When  a  patient  complains  of 
vertigo  as  his  chief  symptom  one  should  therefore 
examine  carefully  for  squint,  for  disease  of  the  outer 
and  middle  ear,  and  for  signs  of  disease  of  the  eighth 
nerve.  One  should  also  investigate  the  condition  of 
muscular  and  common  sensibility  and  inquire  for 
symptoms  pointing  to  gastric  disturbance. 


414  Nervous  System. 

The  ninth  (glosi^opharyiig^eal),  tenth 
(vag^us),  and  eleventh  (spinal  accessory) 
nerves. 

Anatomy. — J'hese  arise  in  order  from  above  downwards 
from,  an  elongated  nucleus  in  the  floor  of  the  fourth  ventricle. 
The  ninth  has  also  an  ascending  root,  beginning  as  low  down 
as  the  fourth  cervical  segment.  They  emerge  by  several 
roots  along  the  lateral  aspect  of  the  medulla,  beginning  above 
in  the  groove  between  the  olive  and  restiform  bodies.  The 
spinal  part  of  the  eleventh  emerges  from  the  lateral  column  of 
the  cord,  beginning  as  low  as  the  sixth  cervical  nerve;  it  passes 
up  through  the  foramen  magnum  to  join  the  medullary 
(accessory)  part,  and  emerges  with  it  through  the  jugular 
foramen.  After  its  emergence  the  two  divisions  of  it  again 
part  company,  the  medullary  or  accessory  portion  joining  the 
vagus. 

Fnnctions. 

The  ninth  (glossopharyngeal)  is  sensory  for  the 
posterior  third  of  the  tongue  and  for  the  mucous 
membrane  of  the  pliar3^nx.  It  is  motor  for  the 
middle  constrictor  of  the  pharynx  and  for  the  stylo- 
pharyngeus.  It  contains  in  part  of  its  course  the 
taste  fibres  for  the  posterior  part  of  the  tongue 
{see  p.  407). 

Ho^v  to  test  the  glossopharyngeal. — The 
ninth  nerve  is  rarely  paralysed  alone.  Paralysis  of  it 
can  only  be  diagnosed  by  examining  its  sensory  func- 
tions. Examine  the  power  of  taste  in  the  posterior 
part  of  the  tongue  (p.  408).  Loss  of  it  may  mean 
paralysis  of  the  trunk  of  the  glosso-pharyngeal 
nerve.  In  root  affections  of  the  nerve  taste  is  not 
implicated,  as  the  taste  fibres  enter  the  brain  by 
the  fifth. 

Tickle  the  back  of  the  pharynx,  and  note  if  the 
reflex  is  present. 

The  tenth  (vagus)  is  motor  for  the  soft  palate 
(with  the  exception,  perhaps,  of  the  tensor  palati), 
pharynx,  and  larynx.  It  must  be  stated,  however, 
that    many   authorities   believe    that   the   palate   is 


Tenth  Nerve.  415 

supplied  by  the  f?pinal  accessory.  It  is  also  sensory 
and  motor  for  the  respiratory  passages,  the  heart,  and 
(through  the  sympathetic  ganglia)  for  most  of  the 
abdominal  ^'iscera. 

The  fibres  for  the  soft  palate  take  origin  in  the 
nucleus  ambiguus,  emerge  in  the  lower  roots  of  the 
vagus,  reach  the  pharyngeal  plexus^  and  thence  pass 
to  the  muscles  of  the  palate. 

The  motor  fibres  for  the  larynx,  the  viscero-motor, 
and  the  cardio- inhibitory  fibres  are  really  derived 
from  the  medullary  or  accessory  part  of  the  spinal 
accessory,  which,  as  we  have  mentioned  (p.  41 4j, 
joins  the  vagus  just  after  emerging  from  the  skull. 

How  to  test  tlie  vagvs. — Paralysis  of  the 
vagus  is  chiefly  evidenced  in  its  palatine  and  laryn- 
geal branches. 

{a)  The  palate. — Ask  the  patient  whether  he 
is  troubled  with  the  regurgitation  of  fluids  through 
his  nose  when  he  tries  to  swallow.  This  is  a  common 
occurrence  in  total  paralysis  of  the  soft  palate,  owing 
to  defective  elevation  of  it  during  swallowing.  For 
a  similar  reason  the  patient  is  unable  to  pronounce 
words  which  require  complete  closure  of  the  naso- 
pharynx. Thus  "  egg '^  becomes  "eng,"'  "rub" 
becomes  "rum,'  and  so  on.  In  unilateral  paralysis 
these  symptoms  are  not  observed. 

For  direct  examination  of  the  soft  palate  place  the 
patient  facing  the  light  with  his  mouth  open,  and  in- 
troduce a  tongue  depressor.  The  position  of  the  uvula 
is  quite  unreliable  as  a  guide  to  the  state  of  the  soft 
palate.  Deviation  of  it  is  not  uncommon  even  in 
health.  One  must  watch  the  movements  of  the  palate 
during  phonation.  Ask  the  patient,  therefore,  to  say 
"  Ah  "  and  observe  whether  both  sides  of  the  palate 
arch  upwards;  in  health  a  sort  of  depression  appears 
in  the  centre  of  the  palate  when  the  patient  says 
"  Ah."    If  one  side  is  paralysed  that  side  will  remain 


4i6  Nervous  System. 

flat  and  immobile,  and  the  median  raphe  will  be  pulled 
towards  the  other  side.  In  bilateral  paralysis  the 
whole  palate  remains  motionless. 

(6)  The  larynx. — The  superior  laryngeal  branch 
of  the  vagus  is  sensory  for  the  larynx  al>ove  the  level 
of  the  true  cords,  and  is  motor  for  the  cricothyroid 
muscle.  Unilateral  paralysis  of  the  nerve  does  not 
produce  any  symptoms.  Bilateral  paralysis  causes 
the  vocal  cords  to  be  relaxed.  The  voice  is  therefore 
hoarse  and  deep,  and  the  utterance  of  high  notes  im- 
possible. 

The  recurrent  laryngeal  branch  supplies  sensation 
to  the  larynx  below  the  level  of  the  cords,  and  motor 
fibres  to  all  the  laryngeal  muscles  except  the  crico- 
thyroid. Paralysis  of  it  leads  to  appearances  which 
are  recognised  by  the  laryngoscope  and  are  described 
at  p.  477. 

The  eleventli. — The  accessory  part  of  this  nerve 
gives  to  the  vagus  its  motor  fibres  for  the  larynx. 
Lesions  of  the  accessory  part,  therefore,  before  its 
junction  with  the  vagus  may  give  rise  to  laryngeal 
paralysis.  The  rest  of  the  nerve  dips  below  the  sterno- 
mastoid  muscle  about  one  inch  below  the  tip  of  the 
mastoid  process,  and  emerges  from  underneath  that 
muscle  again  at  about  the  middle  of  its  posterior 
border.  It  supplies  the  sternomastoid  and  upper 
part  of  the  trapezius.  Lesions  of  it,  therefore,  lead  to 
paralysis  of  these  muscles. 

How  to  test  the  spinal  accessory.  — 
Paralysis  of  the  upper  part  of  the  trapezius  is 
evinced  by  asking  the  patient  to  shrug  his  shoulders 
while  the  observer  offers  passive  resistance  by  press- 
ing on  the  shoulders  from  behind.  Paralysis  of  the 
sternomastoid  causes  difficulty  in  rotation  of  the  head 
towards  the  opposite  side. 

The  twelftli  or  hypoglossal  nerve. 

Anatomy. — The  twelfth  nerve  arises  from  a.nucleus  in  the 


Twelfth  Nerve.  417 

lower  part  of  the  floor  of  the  fourth  ventricle,  close  to  the 
middle  line.  It  emerg-cs  between  the  anterior  pyramid  and  the 
olive.  It  is  a  purely  motor  nerve,  supplying  the  tongue  and 
the  depressors  of  the  hyoid  bone.  Its  cortical  centre  is  in  the 
lower  part  of  the  ascending  frontal  convolution. 

Test. — Ask  the  patient  to  put  out  his  tongue  as 
far  as  possible.  If  the  hypoglossal  Ije  paralysed  the 
tongue,  instead  of  being  protruded  straight,  is  pushed 
over  to  the  paralysed  side.  Be  careful  not  to  mistake 
an  apparent  deviation  of  the  tongue,  really  due  to  the 
mouth  being  twisted  to  one  side,  for  a  real  deviation  of 
it.  Such  an  apparent  deviation  occurs  in  facial  para- 
lysis. Ask  him  also  to  move  his  tongue  from  side  to 
side,  and  to  lick  each  cheek  with  it;  observe  whether  he 
can  do  so  freely.  Note  whether  there  is  any  wasting 
of  the  tongue  and  whether  there  be  any  tremor  or  fibril- 
lary twitching  in  it.  The  presence  of  wasting  indi- 
cates that  the  lesion  is  either  nuclear  or  infranuclear. 

Paralysis  of  the  cervical  sympathetic  may 
be  conveniently  considered  here.  A  complete  descrip- 
tion of  the  functions  and  distribution  of  the  nerve, 
however,  is  not  necessary  in  such  a  work  as  this.  For 
purposes  of  diagnosis  the  fibres  supplied  to  the  eyeball 
are  alone  of  importance.  These  take  origin  in  the  an- 
terior part  of  the  floor  of  the  aqueduct  of  Sylvius, 
pass  down  the  cervical  cord  to  a  centre  in  the  lower 
cervical  and  upper  dorsal  regions  (ciliospinal  centre), 
from  which  the  fibres  emerge  in  the  last  cervical  and 
first  dorsal  nerve  roots  and  pass  to  the  sympathetic 
cord  by  the  rami  communicantes.  From  the  cervical 
sympathetic  cord  the  fibres  pass  along  the  internal 
carotid  to  the  cavernous  plexus,  and  thence  md 
the  ophthalmic  division  of  the  fifth  to  the  eyeball. 
They  convey  the  impulses  which  cause  dilatation  of 
the  pupil,  and  supply  also  the  muscle  of  Miiller.  Para- 
lysis of  the  cervical  sympathetic  is  recognised  by 
the  following  signs  : — Some  recession  of  the  eyeball, 
so  that  the  eye  looks  smaller  than  its  fellow ;  slight 

B  B 


4i8  Nervous  System. 

drooping  of  the  upper  lid ;  contraction  of  the  pupil 
with  absence  of  dilatation  on  shading  the  eye,  or  on  in- 
stillation of  cocaine ;  abolition  of  the  ciliospinal  reflex. 

SECTION  IV.— MOTOR  FUNCTIONS. 

In  investigating  the  motor  functions  of  a  patient, 
one  has  to  satisfy  himself  on  four  separate  points. 

(1)  Is  there  any  muscular  paralysis  or  weakness] 

(2)  Can  the  patient  co-ordinate  his  actions  norm- 

(3)  What  is  the  state  of  nutrition  of  his  muscles  ] 

(4)  Is  there  any  abnormal  muscular  movement 
present  ? 

(I.)  Investig^atioii    of  motor   power. — The 

first  thing  to  be  noted  as  regards  the  patient's  volun- 
tary power  is  whether  or  not  he  is  capable  of  per- 
forming gross  muscular  movements.  Can  he  walk  % 
Can  lie  sit  up  in  bed  ?  Can  he  move  each  of  his  limbs 
as  a  whole  ? 

These  main  points  having  been  determined,  it  may 
be  necessary  to  investigate  the  principal  muscles  and 
groups  of  muscles  separately. 

The  general  rule  for  one's  guidance  in  this  investi- 
gation is  to  ask  the  patient  to  throw  into  action  the 
particular  muscle  or  group  of  muscles  which  one 
wishes  to  test,  whilst  the  observer  offers  to  that  action 
a  greater  or  less  degree  of  passive  resistance.  The 
following  is  the  method  of  procedure  for  the  chief 
muscles  which  one  wishes  to  test : — 

1.  Upper  limb. 

Flexors  of  fingers. — Ask  the  patient  to  squeeze 
your  hand.  If  a  record  of  the  power  of  grasp  be 
desired,  which  can  be  compared  with  the  result  yielded 
in  similar  circumstances  on  another  occasion,  one  should 
make  use  of  the  dynamometer. 

Inter ossei  and  lumhricales. — Paralysis  of  these 
muscles  gives  rise  in    cases    of   some    standing    to  a 


Muscles  of  Upper  Limb.  419 

peculiai'  positiuu  of  tlie  liaiid  known  as  *'  main 
en  g:i'ille "  or  claw-liand.  The  above-mentioned 
muscles  produce  Hexion  of  the  first  phalanges  on  the 
metacai-pals  and  extension  of  the  other  two  phalanges. 
Paralysis  of  them  produces,  by  over-action  of  their 
opponents,  over-extension  of  the  first  phalanges  and 
flexion  of  the  other  two.  The  fingers  are  also  slightly 
separated  from  one  another.  Claw-hand  occurs  in 
some  cases  of  progressive  muscular  atrophy  and, 
in  a  partial  form,  in  paralysis  of  the  ulnar  nerve. 
Claw-foot  is  an  analogous  condition. 

Opponens  pjoUicis. — Ask  the  patient  to  touch  the 
tip  of  his  little  finger  with  the  point  of  his  thumb. 

Adductor  of  thumh. — Ask  the  patient  to  grasp 
a  book  between  the  forefinger  and  thumb. 

Flexors  of  lorist. — The  hand  being  held  with  the 
palm  upwards,  ask  him  to  bring  the  points  of  his 
fingers  towards  the  front  of  the  forearm. 

Extensors  of  icrisf. — The  hand  being  held  with  the 
palm  downwards,  the  observer  grasps  the  patient's 
wT-ist  and  asks  him  to  bend  the  hand  up  backwards 
as  far  as  possible.  If  he  is  unable  to  produce  dorsi- 
flexion  of  the  wrist  some  weakness  or  paralysis  of  the 
extensors  is  present. 

Slight  weakness  of  the  extensors  of  the  wrist  mav 
be  elicited  by  asking  the  patient  to  grasp  something 
firmly  in  his  hand.  If  the  extensors  are  weak  the 
wrist  becomes  flexed  as  he  does  so.  owing  to  the  flexor 
muscles  getting  the  better  of  the  extensors. 

Weakness  or  paralysis  of  the  extensors  of  the 
wrist  leads  to  the  condition  known  as  WTist-drop. 

Supinator  longus. — Place  the  arm  midway  between 
the  prone  and  supine  positions  :  then  ask  the  patient 
to  bend  up  the  forearm  whilst  the  observer  ofiers 
opposition  to  the  act  by  grasping  the  hand.  If  the 
muscle  be  healthy,  it  will  be  seen  and  felt  to  stand 
out  prominently  at  its  upper  part. 


420  Nervous  System. 

Biceps. — The  patient's  elbow  being  held  against  his 
side,  ask  hira  to  bend  "up  the  forearm  while  op])Osition 
is  offered  by  grasping  the  hand  or  wrist.  If  the  biceps 
is  healthy  it  will  be  observed  to  stand  out  prominently 
as  it  contracts. 

The  Triceps  is  tested  by  asking  the  patient  to 
straighten  out  his  forearm  whilst  the  observer  endea- 
vours to  keej:*  it  flexed  by  means  of  passive  resistance. 

Deltoid. — Ask  the  patient  to  lift  his  arms  straight 
out  at  right  angles  to  the  trunk.  In  paralysis  of  the 
deltoid  he  is  unable  to  do  so. 

Pectorals. — Ask  the  patient  to  stretch  his  arms  out 
in  front  of  him,  and  then  to  clap  his  hands  while  the 
observer  endeavours  to  hold  them  apart.  Note 
whether  both  heads  of  the  muscle  are  thrown  into 
contraction  or  not. 

Serratus  magnus. — Ask  the  patient  to  push  against 
resistance.  In  a  healthy  condition  of  the  muscle 
its  various  digitations  will  be  seen  to  stand  out  in 
contraction,  whilst  the  scapula  will  remain  in  close 
ap])osition  to  the  chest  wall.  If  the  muscle  is  para- 
lysed, the  posterior  border  and  inferior  angle  of  the 
scapula  will  come  to  project  more  or  less  when  the 
patient  pushes. 

Latissimus  dor  si. — Ask  the  patient  to  clasp  his 
hands  behind  his  back  while  the  observer,  standing 
behind  the  patient,  offers  passive  resistance  to  the 
downward  and  backward  movement. 

2.  Trunk  muscles. 

Weakness  of  the  muscles  of  the  abdomen  is  in- 
dicated by  the  patient  being  unable  to  raise  himself 
in  bed  without  the  aid  of  his  arms.  To  test  the 
erector  spince  and  muscles  of  the  back,  make  the 
patient  lie  on  his  face  and  try  to  raise  his  head  from 
the  bed  by  extending  the  neck  and  back.  If  the  back 
muscles  are  healthy,  they  will  be  seen  to  stand  out 
prominently  during  this  effort. 


Muscles  of  Lower  Limb.  421 

The  method  of  detecting  paralysis  of  the  dm- 
'pliragm  lias  already  been  described  (p.  227). 

The  trapezius  is  tested  in  its  upper  part  by  asking 
the  patient  to  shrug  his  shoulders  while  tlie  observer 
tries  to  press  them  down  from  behind.  In  its  lower 
part  it  can  be  tested  by  asking  him  to  approximate 
the  shoulder  blades. 

3.  The  head  muscles. — For  the  methods  of 
detecting  weakness  or  paralysis  in  the  muscles  of  the 
liead,  the  reader  is  referred  to  the  section  dealing 
with  the  investigation  of  the  Cranial  ]N^eiwes  (p.  387). 

4.  The  loAver  liiub. 

The  muscles  of  the  foot  are  tested  on  the  same 
lines  as  the  corresponding  muscles  of  the  hand — 
passive  resistance  being  offered  to  their  action  in  each 
case. 

Extensors  of  hnee. — Bend  up  the  patient's  knee, 
and  then,  pressing  with  your  hand  on  the  sole  of  his 
foot,  ask  him  to  try  to  straighten  it  out  again. 

Flexors  of  knee. — Turn  the  patient  on  his  face, 
and  then  ask  him  to  bend  up  the  knee  whilst  the 
observer  endeavours  to  hold  it  down  by  pressing 
upon  the  back  of  the  ankle. 

Extensors  of  thigh. — The  knee  being  extended,  lift 
the  patient's  foot  otf  the  bed,  and  ask  him  to  depress 
it  against  resistance.  If  the  extensors  of  the  hip  are 
paralysed  he  will  be  unable  to  do  so. 

Flexors  of  thigh. — The  knee  being  extended,  ask 
the  patient  to  raise  his  leg  off  the  bed. 

The  adductors  of  the  thigh  are  tested  b}' abducting 
the  limb,  and  then  asking  the  patient  to  bring  it  back 
to  the  middle  line  while  passive  opposition  is  offered 
to  the  act.  In  a  similar  way  the  abductors  are  tested 
by  bringing  the  limb  across  the  middle  line,  and  then 
asking  the  patient  to  move  it  outwards  again. 

Rotators  of  the  thigh. — Turn  the  patient  on  his 
face,   and    bend    the    knee  to    a    right    angle.     Then 


42  2  Nervous  System. 

ask  him  to  roll  the  leg  outwards  or  inwards  whilst 
passive  resistance  is  offered  by  grasping  the  foot. 

If,  on  carrying  out  any  of  these  tests  a  muscle  or 
group  of  muscles  is  found  to  have  only  a  feeble  power 
of  contraction,  paresis  of  it  is  said  to  be  present. 
If  no  contraction  be  elicited  at  all  the  condition  is 
one  of  paralysis. 

The  term  hemiplegia  is  applied  to  a  condition 
in  which  there  is  paralysis  of  one  side  of  the  face  and 
of  the  arm  and  leg  on  the  same  side.  If  the  paralysis 
of  the  arm  and  leg  be  on  one  side,  and  that  of  the 
face  on  the  other,  the  condition  is  one  of  crossed 
paralysis.  The  term  paraplegia  is  applied  to  a 
paralysis  of  the  lower  part  of  the  body ;  the  term 
monoplegia  to  a  paralysis  of  one  arm  (which  is 
therefore  characterised  as  a  brachial  monoplegia), 
one  leg  {crural  monoplegia),  or  one  side  of  the  face 
{facial  monoplegia). 

The  detection  of  paralysis — and  still  more  of 
paresis — in  a  patient  who  is  comatose  is  often  a  very 
difficult  matter.  It  is  to  be  observed,  however,  that 
even  in  such  a  patient  one  can  usually  detect  a  greater 
degree  of  limpness  in  the  paralysed  limb.  If  the  arm, 
for  example,  be  raised  from  the  patient's  side  and 
allowed  to  drop,  it  falls,  if  it  be  paralysed,  just  as  if 
it  did  not  belong  to  the  patient  ;  the  sound  arm  also 
falls,  but  not  in  such  an  utterly  limp  fashion.  The 
distinction,  however,  is  often  by  no  means  easy. 

II.  Investigation  of  muscnlar  co-ordina- 
tion. 

By  muscular  co-ordination  is  meant  the  co-opera- 
tion of  separate  muscles,  or  groups  of  muscles,  in  order 
to  accomplish  a  definite  act.  If  such  co-operation  be 
absent  or  imperfect,  the  performance  of  certain  acts 
becomes  difficult  or  impossible,  and  the  condition  is 
then  said  to  be  one  of  inco-ordination.  The  term 
ataxia  or  ataxy  has  a  similar  meaning. 


Muscular    Co-ordination.  423 

The  co-ordination  or  harmonious  action  of  groups 
of  muscles  is  the  product  of  various  factors,  amongst 
the  chief  of  which  are  sight,  the  muscular  sense,  the 
contractility  and  elasticity  of  the  muscles,  and  in 
the  case  of  some  acts,  at  least,  cutaneous  sensibility. 
If  inco- ordination  be  present,  it  is  not  easy  to  say 
which  of  these  factors  is  at  fault.  ISTor  is  this  neces- 
sary, the  fact  of  in  co-ordination  being  all  that  one 
wishes  to  ascertain.  It  is  usual,  however,  to  eliminate 
the  sense  of  sight,  as  the  help  it  affords  the  patient  is 
so  great  that  it  might  prevent  slight  degrees  of  inco- 
ordination from  being  detected.  The  eyes  should 
therefore  be  bandaged. 

How  to  test  co-ordination. 

1.  In  the  ui^i^ev  limhs. 

The  eyes  being  bandaged,  ask  the  patient  to  touch 
the  point  of  his  nose  first  with  one  forefinger  and 
then  with  the  other.  Or  ask  him  to  bring  the  points 
of  the  two  forefingers  together.  If  he  is  able  to  do 
these  things  successfully,  without  making  random 
shots,  no  inco-ordination  is  present. 

Another  good  test  of  co-ordination  in  the  upper 
limb  is  to  ask  the  patient  to  thread  a  needle.  In 
that  case,  of  course,  the  eyes  must  be  left  uncovered. 

2.  In  the  lower  limhs. 

If  the  patient  is  able  to  walk,  a  good  test  for  co- 
ordination in  the  lower  limbs  consists  in  asking  him 
to  walk  along  a  straight  line — e.g.  a  crack  between  two 
boards  of  the  floor,  or  the  edge  of  a  carpet.  If  inco- 
ordination is  present  he  will  soon  deviate  to  one  side 
or  the  other. 

If  he  cannot  walk,  proceed  as  follows  :  The  eyes 
being  covered,  ask  the  patient,  as  he  lies  in  bed,  to 
touch  the  dorsum  of  one  foot  with  the  great  toe  of 
the  other. 

Another  method  is  to  leave  the  eyes  open  and  then 
to  ask  him  to  follow  with  his  toe  one's  forefinger,  with 


424  Nervous  System. 

which  one  describes  circles  in  tlie  air.  If  he  is  able 
to  describe  the  circles  accurately  his  power  of  coi 
ordination  is  good. 

A  special  test  for  co-ordination  in  the  lower  limbs 
is  to  make  the  patient  stand  with  his  heels  together 
and  his  eyes  shut,  and  to  notice  whether  he  stands 
steadily  or  sways  about.  The  inability  to  do  this, 
which  exists  in  locomotor  ataxy,  is  known  as  Rom- 
l>erg's  !syiiiptoiu.  It  is  due  in  part  usually  to  the 
absence  of  sensation  in  the  soles  of  the  feet,  but  is 
found  even  when  sensation  is  unimpaired. 

III.  The  state  of  nutrition  of  the  muscles. 
— This  is  gauged  roughly  by  pinching  the  muscles, 
and  noting  whether  they  are  firm,  as  in  health,  or 
wasted  and  flabby.  In  the  disease  known  as 
pseudo-hypertrophic  paralysis  some  of  the  muscles 
are  abnormally  firm  and  large.  This  is  especially 
apt  to  be  the  case  with  the  calf  muscles  and  the 
infraspinati.  Such  hypertrophy  must  not  be  mis- 
taken for  a  mere  increased  muscular  development. 
It  is  due  to  an  overgrowth  of  the  interstitial 
tissue  of  the  muscle  at  the  expense  of  the  muscle 
fibres,  and  is  really  a  sign  of  disease.  The  finer 
indications  regarding  muscular  nutrition  which  are 
afforded  by  the  use  of  electrical  stimulation  are  de- 
scribed in  the  section  on  the  Electrical  Examination 
of  Muscles  and  ;^^^erves  (p.  440). 

IV.  Abnormal  muscular  movements.— These 
consist  of  involuntary  muscular  contractions  of  various 
sorts.  The  first  thing  to  note  is  whether  the  move- 
ments are  w^idespread  or  localised. 

If  they  are  confined  to  one  part  of  the  body,  note 
the  joints  at  which  the  movements  occur,  and  the 
muscles  or  groups  of  muscles  involved.  The  term 
spasm  is  often  applied  to  any  exaggerated  and  in- 
voluntary muscular  contraction.  The  contraction  may 
either  be  continuous,  in  which  case  it  is  said  to  be 


Abnormal  Muscular  Movements.       425 


it 


tonic,"  or  there  may  be  a  series  of  sliort  contrac- 
tions with  complete  or  partial  relaxation  of  the  muscle 
in  the  intervals  ;  in  that  case  they  are  spoken  of  as 
"  clonic." 

The  term  contractnre  or  rigidity  is  usually 
applied  to  that  continuous  spasm  of  groups  of  muscles 
often  observed  in  cases  of  paralysis  due  to  cerebral 
lesions.  It  is  doubtful,  however,  whether  this  is  a 
true  muscular  contraction. 

Tetanic  spasm  is  observed  in  its  completest  form 
in  tetanus,  strychnine  poisoning,  hydrophobia,  and 
some  forms  of  hysterical  fits.  It  may  lead  to  a  bend- 
ing of  the  whole  body  backwards  {opisthotonos)  or 
sidewards  (j)leitrosthotonos)  or  forwards  {emprostho- 
tonos). 

The  term  tetany  is  applied  to  a  peculiar  form  of 
tonic  spasm  affecting  the  hands  and  feet.  The  fingers 
are  pressed  together,  flexed  at  the  metarcarpo-phalan- 
geal  joints,  but  extended  at  their  phalangeal  articula- 
tions. The  thumb  is  tucked  in  under  cover  of  the 
fingers.  The  hand  therefore  assumes  a  conical  shape, 
and  is  sometimes  said  to  be  in  the  "obstetric  position," 
that  being  the  position  in  which  the  accoucheur  holds 
his  hand  when  introducing  it  into  the  vagina.  The 
wrist  is  also  flexed.  In  the  foot  one  finds  marked 
flexion  of  the  toes  and  anterior  part  of  the  foot,  some- 
times also  of  the  ankle.  Tetany  is  chiefly  a  disease  of 
infancy,  but  is  sometimes  met  with  in  adults  who 
have  dilatation  of  the  stomach. 

Clonic  spasms  are  of  various  degrees  of  severity. 
If  very  widespread  they  are  spoken  of  as  convul- 
sions, and  are  seen  typically  in  epilepsy.  If  con- 
vulsions be  present,  study  their  onset,  noting  whether 
the  contractions  appear  in  all  the  affected  muscles 
simultaneously,  or  whether  one  group  of  muscles  is 
first  attected,  the  spasm  spreading  to  other  groups' by 
degrees.     If  the  latter  be  the  mode  of  invasion,  it 


426  Nervous  System. 

indicates  a  suread  of  the  irritation  alonsf  the  sur- 
face  of  the  cortex  cerebri,  and  occurs  typically  in 
Jacksonian  epilepsy.  The  mildest  variety  of  clonic 
muscular  contraction  is  termed  tremor. 

Tremor  may  be  either  jine  or  coarse.  Fine  tremor 
is  usually  more  easily  felt  than  seen.  It  occurs  in 
exophthalmic  goitre  and  in  some  forms  of  metallic 
poisoning.  All  forms  of  tremor  are  most  easily  seen 
by  increasing  the  leverage  at  which  the  affected 
muscles  act.  Thus  tremor  of  the  upper  limbs  is  often 
brought  out  by  getting  the  patient  to  extend  his  arms 
in  front  of  him.  In  describing  tremor,  always  note 
whether  it  is  constantly  present  or  whether  it  is 
affected  in  any  way  by  voluntary  muscular  action. 
Ask  the  patient  to  lift  a  glass  of  water  to  his  lips, 
and  note  whether  the  tremor  is  increased  thereby  (as 
it  is,  for  example,  in  cases  of  disseminated  sclerosis), 
or  whether  it  is  diminished  or  altogether  abolished. 

Tremor  which  only  comes  on  when  the  patient 
attempts  to  use  the  affected  muscles  is  sometimes 
described  as  "  intention  "  tremor. 

Clonic  contraction  of  individual  fibres  or  bundles 
of  fibres  in  a  muscle  is  termed  fibrillary  twitching^. 
It  is  seen  in  many  cases  of  progressive  muscular 
atrophy,  and  indicates  an  abnormal  state  of  nutrition 
in  the  spinal  cells  connected  with  the  affected  fibres. 

The  term  choreic  is  ajiplied  to  involuntary 
movements  of  a  purpose-like  character  occurring  in 
individual  muscles  or  groups  of  muscles.  Such  move- 
ments are  seen  most  typically  in  chorea  minor  or 
St.  Vitus's  dance.  They  consist  of  abrupt  involun- 
tary twitchings  or  contractions  which  cause  the 
patient  (usually  a  child)  to  seem  fidgety  and  un- 
settled. They  are  increased  by  mental  agitation,  but 
are  often  diminished  by  voluntary  muscular  effort. 
If  the  movements  are  limited  to  one  side  of  the  body 
the  term  hemichorea  is  applied. 


Sexso/^v  Fu.yctions.  427 

Choreic  movements,  if  slight,  can  be  elicited  in 
two  ways.  Firstly,  one  may  ask  tlie  patient  to  hold 
both  hands  straight  up  above  the  head  ;  or,  secondly, 
one  may  ask  the  patient  to  spread  out  his  hands, 
palms  downwards,  on  the  extended  hands  of  the 
observer.  In  the  former  case  it  may  be  observed  that 
the  patient  is  unable  to  hold  up  his  hands  steadily  for 
any  length  of  time  ;  in  the  latter  one  may  notice  that 
little  twitchy  movements  soon  become  evident  in  the 
patient's  fingers. 

If  the  patient  is  able  to  write  at  all,  one  may 
get  him  to  scrawl  his  name  with  the  affected  hand, 
and  keep  the  result  for  purposes  of  comparison  later. 
In  this  way  one  is  able  to  gauge  any  increase  or 
diminution  in  the  choreic  movements. 

The  last  point  to  be  noted  regarding  any  abnormal 
muscular  movement  is  whether  or  not  it  persists 
during  sleep. 

The  term  athetosis  is  used  to  describe  a  slow 
muscular  contraction  Avhich  leads  to  continuous  and 
deliberate  twisting  movements,  specially  affecting  the 
hands  and  feet. 

SECTION    v.— SENSORY   FUNCTIONS. 

In  investigating  the  sensory  functions  of  a  patient, 
we  have  to  test  the  acuteness  of  the  followino-  forms 
of  sensibility  : — 

(1)  Common  sensibility.  This  includes  the  powers 
of  appreciating  touch  and  pressure. 

(2)  Sensibility  to  pain. 

(3)  The  temperature  sense. 

(4)  The  muscular  sense. 

In  addition,  one  has  to  note  the  presence  or  absence 
of  any  abnormal  sensations. 

At  the  outset  it  is  well  to  explain  to  the  patient 
the  nature  of  the  tests  to  be  performed,  so  as  to  secure, 
as  far  as  possible,  his   intelligent  co-operation.      The 


428  Nervous  System. 

eyes  should  then  be  bandaged,  and  the  different  forms 
of  sensibility  tested  as  follows  : — 
1.  Commoii  iseii!sil>jlity. 

(a)  Touch. — The  point  of  the  finger  or,  preferably, 
the  feather  end  of  a  quill  pen  may  be  used  as  a  stimulus. 
For  carefully  mapping  out  areas  of  altered  sensibility 
a  small  cone  of  cotton  wool  is  best.  It  is  so  light  that 
the  element  of  pressure  is  entirely  eliminated.  A  fine 
camel-hair  brush  also  answers  the  purpose  very  well. 

Tell  the  patient  to  say  "Now"  whenever  he  feels 
a  touch.  Compare  corresponding  points  on  opposite 
sides  of  the  body,  and  employ  every  now  and  then  a 
negative  test,  asking  the  patient  if  he  feels  you  touch 
him,  in  order  to  prevent  his  making  random  replies. 
Ask  him  also  to  localise  the  stimulus  by  pointing  to 
the  exact  position  of  the  spot  touched.  This  is  im- 
portant, as  a  patient  may  be  able  to  feel  the  stimulus 
and  yet  not  be  able  to  localise  it. 

Sensibility  to  touch  may  be  altered  in  various  ways. 
(1)  It  may  be  entirely  abolished.  This  constitutes 
aueesthesia.  If  the  abolition  affects  the  whole  of 
one  side  of  the  body,  it  is  termed  hemiancesthesia.  If 
the  existence  of  anaesthesia  be  discovered,  one  must 
at  once  proceed  to  mark  out  its  exact  extent  and 
boundaries,  (2)  It  may  be  exaggerated,  so  that  what 
should  in  health  be  felt  as  a  mere  touch  produces 
a  painful  impression  resembling  pricking  or  burning. 
This  constitutes  liypersestliesia.  If  hypersesthesia 
be  discovered,  its  extent  should  be  carefully  mapped 
out.  Hjrpersesthetic  spots  are  sometimes  met  with, 
especially  in  hysterical  patients.  The  commonest  sites 
for  these  are  over  the  brim  of  the  pelvis,  in  the  infra- 
mammary  region,  along  the  vertebral  column,  and  on 
the  scalp.  Pressure  on  such  spots  may  sometimes 
induce  hysterical  fits.  If  that  occurs,  the  spots  are 
spoken  of  as  "  hysterogenetic."  (3)  Sensation  may 
be  a})preciated  well  enough,  but  there  may  be  great 


Sejvsorv  Functions.  429 

delay  in  its  conduction,  an  appreciable  interval  occur- 
ring between  the  application  of  the  stimulus  and 
the  response  of  the  patient.  This  delayed  coii- 
duclioii  exists  not  infrequently  in  cases  of  alcoholic 
neuritis  and  locomotor  ataxy.  (4)  The  stimulus  may 
be  badly  localised,  the  patient  believing,  for  example, 
that  the  outer  side  of  a  limb  was  touched  when  the 
stimulus  was  really  applied  to  its  inner  aspect.  Some- 
times a  touch  on  one  side  of  the  body  is  referred  to 
a  corresponding  point  on  the  opposite  side.  This  is 
termed  alloclieiria. 

(5)  Pressure. — This  is  tested  by  supporting  the 
limb  or  part  to  be  tested  in  such  a  way  as  to  eliminate 
any  muscular  action  on  the  part  of  the  patient,  and 
then  laying  different  weights  on  the  surface,  and 
asking  the  patient  which  feels  heavier.  Different 
coins  of  the  same  size — e.g.  sovereign  and  farthing — 
answer  the  purpose  well  enough. 

2.  Sensibility  to  pain. 

The  point  of  a  quill  pen  may  be  used  as  a  stimulus. 
The  point  of  a  pin  or  needle  has  the  disadvantage  of 
being  so  fine  that  it  may  miss  the  nerve  endings.  The 
application  of  a  faradic  current  is  also  an  excellent 
method  of  testing  sensibility  to  pain.  It  enables  one 
to  gauge  degrees  of  sensibility  by  noting  what  strength 
of  current  is  required  to  cause  pain,  and  then  com- 
paring the  result  with  the  corresponding  area  on  the 
opposite  side. 

Absence  of  the  sense  of  pain  is  termed  anal- 
g^esia ;  an  exaggerated  sensibility  to  pain,  so  that  a 
miild  stimulus  produces  an  unusual  degree  of  suffering, 
is  termed  hyperalgesia. 

3.  Temperature  sense. — Use  test  tubes  of 
hot  and  cold  water.  Touch  the  part  to  be  investigated 
with  each  in  turn,  and  ask  the  patient  whether  it 
feels  hot  or  cold.  Note  whether  he  calls  hot  "  cold  " 
or  cold  "hot,"  or  whether  he  does  both. 


43°  Nervous  System. 

It  should  be  noted  that  the  different  forms  of 
sensibility  already  mentioned  inay  require  to  be  tested 
on  the  accessible  mucous  membranes  as  well  as  on  the 
skin  surfaces.  The  sensibility  of  some  viscera  is  also 
of  importance.  Thus  the  absence  of  pain  on  squeezing 
the  testicle  may  be  an  early  sign  of  locomotor  ataxy. 

4.  Muscular  sense. — This  demands  the  in- 
vestigation of  two  separate  points. 

{a)  The  patient's  power  of  estimating  weights. 

(p)  His  power  of  appreciating  the  position  of  his 
limbs. 

ici)  Sense  of  weig^ht. — Place  in  the  patient's 
hand  substances  which  resemble  one  another  as  far 
as  possible  in  every  respect  except  as  regards  weight. 
Metal  balls  covered  with  leather,  some  being  solid 
and  others  hollow,  are  often  used  for  the  purpose. 
In  their  absence  one  may  use  two  match  boxes,  one 
full,  the  other  empty,  or  some  other  extemporised 
device.  A  solid  ball  and  a  hollow  one  may  be  placed 
one  in  the  patient's  right  hand  and  the  other  in  his 
left,  and  he  is  then  asked  to  state  which  is  the 
heavier;  or  one  hand  may  be  tested  at  a  time,  the 
balls  being  lifted  one  immediately  after  the  other.  If 
the  leg  is  being  investigated,  the  weights  should 
be  placed  in  a  handkerchief  and  slung  round  the 
patient's  ankle. 

(6)  Sense  of  position. — The  patient's  eyes 
being  carefully  shut,  take  hold  of  one  of  his  limbs  and 
move  it  about  in  various  directions  through  the  air, 
finally  leaving  it  in  some  definite  position,  say  semi- 
flexed and  slightly  elevated;  then  ask  him  to  put  the 
corresponding  limb  in  a  similar  position.  If  there 
be  no  paralysis  of  the  latter  and  yet  the  patient  is 
unable  to  imitate  with  it  the  position  of  the  other, 
then  there  is  reason  to  believe  that  the  sense  of 
position  is  impaired. 

In  testing  a  patient's  sense  of    position    in  this 


Reflex  Functions,  431 

manner,  be  careful  not  to  allow  the  part  tested  to 
touch  any  other  skin  surface ;  otherwise,  the  patient 
will  be  able  to  appreciate  its  position  by  the  informa- 
tion derived  from  his  ordinary  sense  of  touch.* 

Are  tliere  any  abnormal  sensations  pre- 
sent I — These  are  termed  paraestliesise,  and  con- 
sist in  various  sensations  experienced  by  the  patient 
in  the  absence  of  any  outward  stimulus.  The  com- 
monest of  these  are  a  feeling  of  "  needles  and  pins," 
of  numbness,  of  heats  or  chills,  of  pressure  or  tight- 
ness (a  good  examj)le  of  the  latter  being  the  "girdle 
pain "  of  locomotor  ataxy),  of  itching  —  sometimes 
termed  "pruritus" — or  a  feeling  as  if  insects  were 
crawling  over  the  body  (formication). 

The  term  anra  is  applied  to  the  curious  par- 
aestliesise which  frequently  precede  an  epileptic  fit 
and  serve  as  a  warning  of  its  approach. 

SECTION  VL— REFLEX  FUNCTIONS. 

There  are  three  classes  of  reflexes  which  one  has  to 
test. 

(1)  The  superficial  reflexes ; 

(2)  The  deep  or  tendon  reflexes  ; 

(3)  The  organic  reflexes. 

We  shall  consider  these  separately. 

1.  The  snperficial  reflexes.  In  these  the 
simplest  form  of  reflex  action  is  concerned.  On  stimu- 
lation of  a  certain  part  of  skin  or  mucous  membrane 
contraction  of  certain  muscles  results.  The  path  of 
the  impulse  is  by  the  sensory  nerve  fibres  to  the  grey 

*  A  very  delicate  test  for  defective  muscular  sense  (and 
therefore  for  inco-ordination)  in  the  upper  limbs  consists  in 
shutting  the  patient's  eyes  and  then  making  him  hold  his  arms 
straight  out  in  front  of  him  with  the  fingers  in  a  horizontal  row. 
After  a  moment  or  two,  if  the  muscular  sense  be  defective,  the 
fingers  cease  to  remain  in  an  even  line.  Some  will  rise  a  little, 
others  fall,  or  even  become  twisted  in  below  the  rest. 


432  Nervous  System. 

matter  of  the  cord  or  a  sensory  centre  in  the  brain, 
thence  by  motor  nerve  fibres  to  the  muscle.  A 
lesion  in  any  part  of  this  path  causes  the  reflex  to 
disappear.  Thus  anaesthesia  of  the  skin,  disease  of 
the  sensory  fibres  or  posterior  nerve  roots,  changes  in 
the  grey  matter  of  the  cord,  lesions  of  the  motor 
nerve  fibres  or  of  the  fibres  of  the  muscles,  may  all 
cause  abolition  of  the  superficial  reflexes.  In  addition 
to  this,  it  must  be  borne  in  mind  that  the  reflex 
excitability  of  some  individuals  is  normally  very 
much  o-reater  than  that  of  others,  and  this  makes  it 
difficult  for  one  to  estimate  the  value  of  slight 
alterations  in  the  reflexes  unless  the  lesion  is 
unilateral,  in  which  case  the  healthy  side  can  be 
taken  as  a  standard  of  comparison.  The  investiga- 
tion of  the  superficial  reflexes  is  of  more  value  as 
affording  information  regarding  the  health  or  other- 
wise of  the  reflex  arc  concerned  than  as  a  guide  to 
the  presence  or  absence  of  disease  elsewhere.  In 
hemiplegia  the  superficial  reflexes  are  usually  di- 
minished on  the  healthy  side.  Exaggeration  of  both 
knee  jerks  along  with  diminution  of  the  plantar  re- 
flexes is  a  combination  characteristic  of  many  cases 
of  functional  paraplegia. 

The  chief  superficial  reflexes  of  spinal  origin,  their 
nature,  the  mode  of  obtaining  them,  and  the  level  of 
the  cord  concerned  in  their  production  is  given  in 
the  table  on  p.  433. 

The  following  superficial  reflexes  are  dependent  on 
cranial  nerves  : — 

(1)  Coiijiiiictival. — Elicited  by  touching  the 
conjunctiva,  resulting  in  contraction  of  the  orbicularis 
palpebrarum.  The  nerves  concerned  are  the  fifth 
(sensory)  and  the  seventh  (motor). 

(2)  Pupil  reflexes. — {See  pp.  402  and  454). 

(3)  Palate  reflex. — Elevation  of  the  palate  on 
touching    the    mucous    membrane   covering    it.     The 


Reflex  Functions. 


433 


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434  Nervous  System. 

nerves  concerned  are  the  glossopharyngeal  and  the 
vagus  (or  spinal  accessory  ?). 

2.  Deep  or  tendon  reflexes. — If  a  muscle  be 
put  upon  the  stretch  and  its  tendon  be  then  sharply 
struck,  the  muscle  immediately  contracts.  This  is 
spoken  of  as  a  deep  or  tendon  reflex.  It  is  very 
doubtful,  however,  whether  one  is  correct  in  speaking 
of  it  as  a  reflex  at  all.  It  would  seem  that  the  con- 
traction of  the  muscle  follows  too  rapidly  on  the 
blow  upon  the  tendon  to  permit  of  there  being  time 
for  a  reflex  arc  being  traversed.  What  really  happens 
is  probably  this.  The  stretching  of  the  muscle  reflexly 
increases  its  "  tone."  When  the  tone  is  thus  raised 
any  mechanical  stimulus,  in  this  case  the  blow  upon 
the  tendon,  by  suddenly  increasing  the  tension  of 
the  muscle,  excites  in  it  a  direct  contraction.  The 
only  point  where  a  reflex  act  really  comes  in, 
therefore,  is  in  the  preliminary  raising  of  the 
muscle  tone.  Without  this  increase  of  tone,  how- 
ever, the  subsequent  direct  contraction  would  be 
impossible. 

We  have  already  indicated  (p.  363)  that  the 
''tone"  of  a  muscle  is  dependent  upon  the  cells  in 
the  anterior  cornua  of  the  spinal  cord — i.e.  the  lower 
neurons.  When  the  control  of  the  upper  neurons 
over  the  lower  is  cut  off",  the  latter  produce  an 
increased  "  tone  "  in  the  muscles,  with  the  result  that 
the  tendon  reflexes  are  more  easily  excited  than 
normal.  In  other  words,  their  reflexes  are  increased 
or  exaggerated.  Exaggeration  of  tendon  reflexes, 
therefore,  is  characteristic  of  lesions  affecting  the 
upper  neurons — i.e.  the  cerebral  cortex,  or  the  fibres 
passing  from  it  to  the  anterior  horns  of  the  cord.  A 
similar  exaggeration  may  be  brought  about  by  any- 
thing which  stimulates  the  lower  neurons,  thus 
making  them  more  able  to  resist  the  controlling 
influence  of  the  upper.     Strychnine  and    the  toxin 


Reflex  Functions.  435 

of  tetanus  are  able  to  do  this,  and  therefore  produce 
an  increase  of  the  tendon  reflexes. 

On  the  other  hand,  anything  which  impairs  the 
activity  of  the  lower  neuron  will  cause  a  diminution 
in  the  tone  of  the  muscles,  and  will  thus  make  the 
tendon  reflexes  correspondingly  difficult  to  elicit. 
Diminution  or  abolition  of  the  tendon  reflexes  is 
therefore  characteristic  of  lesions  affecting  the  lower 
or  spinal  neuron.  Of  course,  any  disease  of  the 
muscle  fibres  themselves,  or  of  the  sensory  fibres 
which  proceed  from  the  muscle  to  the  spinal  cord, 
and  along  which  the  stimulus  travels  when  the 
muscle  is  first  stretched,  which  stimulus  causes  the 
reflex  increase  of  tone,  will  also  cause  a  diminution 
of  the  tendon  reflexes  by  preventing  the  necessary 
increase  of  tone  from  taking  place.  Hence  it  is  that 
in  locomotor  ataxy,  in  which  the  posterior  roots  are 
nmch  involved,  the  deep  reflexes  are  absent. 

There  is  only  one  point  more  to  be  referred  to, 
and  it  is  rather  a  confusing  one.  In  a  lesion — e.g.  a 
fracture  dislocation — which  produced  complete  trans- 
verse destruction  of  the  cord  at  any  level,  one  might 
expect  that,  owing  to  the  cerebral  influence  being  cut 
ofi*,  all  the  deep  reflexes  below  that  level  would  be 
exaggerated.  This,  however,  is  not  the  case.  The 
reflexes  in  that  condition  are  (as  a  rule)  totally 
abolished.  The  explanation  of  this  apparent  anomaly 
is  still  a  little  doubtful.  It  has  been  supposed  by 
some  that  it  is  to  be  attributed  to  the  cutting  off"  of 
a  cerebellar  influence  which  descends  to  the  cells  of 
the  anterior  cornua,  and,  so  to  speak,  energises  them, 
so  that  they  are  able  to  maintain  the  tone  of  the 
muscles.  It  must  be  admitted,  however,  that  experi- 
mental evidence  is  totally  opposed  to  this  conclusion, 
as  lesions  of  the  cerebellum  are  followed  by  exaggera- 
tion and  not  by  abolition  of  the  deep  reflexes. 

The  knee  jerk  or  patellar  tendon  reflex  is 


436  ^ERVOus  System. 

the  best  known  of  the  deep  reflexes.  It  consists  in  a 
contraction  of  the  quadriceps  extensor  when  the 
patellar  tendon  is  tapped.  The  spinal  segments  con- 
cerned are  the  second  and  third  lumbar. 

HoiD  to  elicit  the  knee  jerk. — If  the  patient  is  able 
to  sit  up,  get  him  to  sit  on  a  chair  or  on  the  edge 
of  the  bed  and  cross  one  knee  over  the  other.  If 
he  is  unable  to  effect  the  latter,  pass  your  wrist 
under  the  knee  to  be  tested,  resting  your  hand  on 
the  opposite  knee  and  allowing  the  patient's  leg 
to  swing  suspended,  as  it  were,  on  the  back  of 
your  wrist.  If  he  cannot  sit  up,  bend  the  knee  up  a 
little  as  he  lies  on  his  back  and  support  it  by  allow- 
ing it  to  rest  on  your  hand  or  the  back  of  your  wrist. 

The  result  of  this  disposition  of  the  limb  is 
slightly  to  stretch  the  quadriceps  extensor,  and  so 
refiexly  to  increase  its  tone.  The  next  thing  to  do  is 
to  try  to  divert  the  patient's  attention.  This  may  be 
done  by  asking  him  to  "  let  the  leg  hang  as  if  it 
did  not  belong  to  him,"  or  by  engaging  him  in 
conversation.  The  patellar  tendon  must  then  be  struck 
a  sharp  blow  midway  between  the  patella  and  its 
insertion.  The  edge  of  the  hand  may  be  used  for 
the  purpose,  or  the  edge  of  a  thin  book,  or  the 
ear  piece  of  a  stethoscope,  especially  if  it  be  sur- 
rounded by  a  rim  of  solid  indiarubber.  A  percussion 
hammer  is  also  a  good  instrument  for  the  purpose. 

Immediately  after  the  blow  the  foot  will  be  ob- 
served to  be  jerked  up  from  the  sudden  contraction  of 
the  muscle. 

The  briskness  of  the  knee  jerk  varies  greatly  in 
different  individuals.  In  health,  however,  it  is  hardly 
ever  entirely  absent.  Sometimes  one  is  unable  to 
elicit  it  without  having  recourse  to  what  is  known  as 
*' reinforceiiieiit  "  of  the  knee  jerk.  This  consists 
in  asking  the  patient  to  make  some  strong  voluntary 
muscular  effort  with  the  upper  limbs.     One  may  ask 


Reflex  Functions.  437 

him,  for  example,  to  hook  the  fingers  of  the  two 
hands  together  and  then  to  pull  them  against  one 
another  as  hard  as  possible.  Whilst  he  is  doing  so 
one  tries  to  elicit  the  knee  jerk,  and  one  usually  gets 
it  more  readily  than  under  ordinary  conditions. 
How  reinforcement  acts  it  is  a  little  ditficult  to  say. 
According  to  some,  it  is  by  increasing  the  general 
muscular  tone  throughout  the  body ;  according  to 
others,  it  acts  by  diminishing  the  inhibitory  cerebral 
control. 

The  following  tendon  reflexes  are  similar  in  nature 
to  the  knee  jerk,  but — probably  owing  to  mechanical 
difficulties  in  producing  adequate  stretching  of  the 
muscle — are  not  usually  so  easy  to  obtain  in  health, 
and  may  indeed  be  entirely  absent. 

Ankle  jerk. — ^Grasp  the  dorsum  of  the  foot  with 
one  hand  and  hold  up  the  leg  with  it.  Slightly 
dorsiflex  the  foot  so  as  to  put  the  tendo  Achillis 
OQ  the  stretch,  then  with  the  other  hand  sharply 
flick  the  latter  on  its  under  surface.  A  sharp  con- 
traction of  the  calf  muscles  results. 

Adductor  jerk  is  produced  by  abducting  the 
thigh  and  tapping  the  tendon  of  the  adductor 
magnus.  Contraction  of  the  adductors  results. 
Sometimes  in  patients  who  have  very  exaggerated 
reflexes  one  finds  that  on  tapping  the  patellar  tendon 
a  sudden  contraction  occurs  in  the  adductor  muscles 
of  the  opposite  thigh.  This  is  termed  the  "  crossed 
adductor  jerk."  Its  explaaation  is  still  rather 
obscure,  but  it  is  apparently  a  truly  reflex  pheno- 
menon. 

Triceps  or  elbow  jerk. — Flex  the  elbow  to 
more  than  a  right  angle,  then  tap  just  above  the 
olecranon.  The  triceps  contracts.  The  reflex  depends 
upon  the  sixth  cervical  segment. 

Supinator  jerk.  —  Produced  by  tapping  the 
supinator  tendon  just  above  its  insertion   into   the 


43 8  Nervous  System. 

styloid  process  of  the  radius.    The  fifth  cervical  is  the 
cord  segment  concerned. 

liVrist  jerk  is  produced  by  letting  the  hand  hang 
down,  and  then  striking  the  extensor  tendons  just 
above  the  wrist.  The  hand  is  jerked  up.  This  reflex 
depends  upon  the  sixth  cervical  segment. 

Jaw  jerk. — Ask  the  patient  to  open  his  mouth, 
but  not  too  widely.  Place  one  finger  firmly  on  his 
chin  and  then  tap  it  suddenly  with  the  other  hand 
as  in  percussion.  A  contraction  of  the  muscles  that 
close  the  jaw  results.  This  jerk  is  never  present  in 
health.  The  motor  nucleus  of  the  fifth  nerve  is  the 
centre  involved. 

The  term  "clonus"  is  applied  to  the  following 
tendon  reflexes  : — 

Ankle  clonus. — To  elicit  this  phenomenon,  bend 
the  patient's  knee  slightly  and  support  it  with  one 
hand,  grasp  the  fore  part  of  the  foot  with  the  other 
hand,  and  suddenly  dorsiflex  the  foot.  The  sudden 
strain  put  upon  the  calf  muscles  causes  them  to  con- 
tract. The  pressure  of  the  hand  upon  the  sole  of  the 
foot  is  meanwhile  continued  and  when  the  contraction 
ceases  causes  the  calf  muscles  again  to  become  tense, 
and  so  produces  another  contraction  in  the  latter.  In 
this  way  a  whole  series  of  contractions — i.e.  a  clonus 
— results. 

The  relative  tendency  to  the  development  of  ankle 
clonus  on  the  two  sides  is  best  estimated  by  slowly 
dorsiflexing  the  foot  and  observing  the  exact  point 
at  which  the  movements  first  begin.  The  less  the 
degree  of  dorsiflexion  required  to  produce  the  clonus 
the  greater  is  the  tendency  to  the  development  of 
the  latter. 

Ankle  clonus  is  nearly  always  a  sign  of  disease. 
The  spinal  segments  concerned  in  it  are  the  first  to 
the  third  sacral. 

Knee  clonus. — In  cases  where  the  knee  jerk  is 


Organic  Reflexes.  439 

exaggerated,  one  can  sometimes  elicit  a  knee  clonus 
by  extending  the  patient's  leg  and  then  suddenly 
pushing  down  the  patella  towards  the  foot.  If  the 
pressure  on  the  latter  be  continued,  a  series  of  clonic 
contractions  of  the  quadriceps  can  often  be  produced. 

3.  Organic  reflexes. — This  term  includes  such 
processes  as  respiration,  deglutition,  micturition,  and 
defsecation.  They  depend  upon  complex  muscular 
movements  excited  either  by  stimulation  of  mucous 
membranes  or,  in  the  case  of  respiration,  of  a  centre 
in  the  medulla. 

One  should  always  ascertain  from  the  patient 
whether  he  has  any  difficulty  in  swallowing,  noting 
specially  whether  there  is  any  regurgitation  of  food 
through  the  nose.  The  function  of  deg-liitition 
does  not  usually  require  to  be  specially  tested  beyond 
the  examination  necessary  to  exclude  the  existence 
of  an  obstruction  (p.  47). 

Defsccatioii. — The  patient  should  be  questioned 
as  to  any  difficulty  in  the  act,  and  as  to  the  presence 
or  absence  of  tenesmus.  Note  also  the  occurrence  or 
not  of  incontinence  of  faeces. 

The  reflex  action  of  the  anal  sphincter  may  be 
tested  by  introducing  the  oiled  finger  into  the  anus, 
and  noting  whether  contraction  of  the  sphincter  occurs 
with  normal  force,  whether  it  be  weak  or  altogether 
inactive,  or  whether  there  is  any  spasm  excited. 

The  activity  of  the  anal  sphincter  reflex  may  also 
be  tested  by  pricking  the  skin  in  the  neighbourhood 
of  the  anus.  Under  normal  conditions  a  brisk  con- 
traction of  the  sphincter  should  immediately  be  visible. 

Mieturitioii. — The  patient  should  be  questioned 
as  to  difficulty  or  pain  in  the  act  {see  p.  9).  One 
should  then  note  whether  there  is  either  retention 
of  urine  or  incontinence  of  it.  If  there  be  incon- 
tinence, ascertain  by  the  use  of  the  catheter  whether 
it  be  due  to  the  overflow  from   a  distended  bladder  or 


440 


Nervous  System. 


whether  it  be  a  reflex  incontinence — i.e.  whether 
the  bladder  merely  fills  up  and  then  empties  itself 
completely  by  reflex  action. 

The    centres    for    the   bladder   and   rectum   are 


HL  frontalis 

Vppir  Iraneh  o/faeial 

il.  corrag.  superoil. 

M,  orbic.  palpelir. 
ITasal  muscles  | 

M.  zygomatici 

M.  orbioul.  oris  •[ 

Ifiddle  branch  qf facial 

H.  masseter 

M.  levator  mentl 

M.  qnadr.  meuti 

2i.  triang.  menti 

Hypoglossal  n. 

Lover  braiuh  of  facial 

'il.  platysma  myoid. 
nyoid  muscles  | 

IkL  omohyoideus 


Ant.  thoracic  n. 
(i&L  pectoral.) 


Region  of  central 
conTolutiona 

Region  of  3rd  frontal 
conr.  and  island 
of  Reil  (centre  fair 
speech) 

M.  temporalis 

Upper  branch  of  facial 
in  front  of  the  ear 

Facia/  n.  (trunk) 
Post,  auricular  n, 
ifiddle  branch  of  facial 
Loicer  branch  (if facial 
M.  splenias 

51  sternocleido- 
mastoideu3 

Spinal  accessory  ru. 

il.  levator  anguli  scapuJ. 

51.  cucuUaria 

Dorsalis  scapuice 

Axillary  n. 


Zong  thoracic  n.  (IL 
Eerrat.aut.maj.) 


fhrenien.    Supraclavicular  point.      Brachial  plexvtt 
(Erb's  point.  M.  deltoi.l., 
biceps,  brachialis  intern, 
and  supin.  long.) 

Fig.  120. — Motor  points,  face  and  neck. 


situated  in  the  fourth  and   fifth  sacral  segments  of 
the  cord. 

SECTION    YIL— ELECTRICAL    EXAMINA- 
TION OF  MUSCLES  AND  NERVES. 

1.  Apparatus. — For  the  purposes  of  diagnosis  as 
distinguished  from  therapeutics  electricity  is  applied  in 
three  forms  :    First  as  the  continuous  current,  second 


Electrical  Ex  a  mina  tion. 


441 


ff.  fleltoia. 
(lunder  part) 


Fadiat  Kerv 

M.  bracliial.  intern. 

M.  supinator  long. 
M.  radial,  est.  long, 
AI,  radial,  est.  brev. 

11.  extensor  digit, 
communis 

M.  extensor  indicis 

M.  abductor  pollic.  long. 
M.  esteusor  pollic,  brcT. 


H.  intcross.  doisol.  I 

etn. 


M.  triceps  (caput 
longum) 


M.  triceps  (caput 
extern.) 


M.  ulnar,  extern. 
M.  supinat.  brev. 

M.  extens.  digiti  minim, 
M.  extens,  indicis 

I  M,  extens.  poll.  long. 


M.  abduct,  digit,  min. 

1  M.  inteross.  dorsaU 
j        IILetlY. 


Fig.  121.— Motor  points,  back  of  arm. 

as  tlie  faradic  current,  third  by  using  the  discharge 
through  Crookes's  tubes,  with  high  vacua  and  suitable 
internal  arrangements,  for  the  purposes  of  skiagraphy 
by  the   X  rays   described   by  Prof.   Rontgen.      The 


442 


Nervous  System. 


11.  triceps  (long  Lead) 

VL  triceps  (inner  head) 
"Ulnar  n,  | 


M.  flexor  carpi  nlnaris 


IL  flex,  digitor.  commun, 
profund. 


M,  flex,  digitor.  snbUm. 
(digiti  II.  et  IIL) 

M.  flex,  digit,  subl.  (digit, 
iudicis  et  minimi) 

Ulnar  n. 


Jll.  palmaris  brev. 

M.  abductor  digiti  Tiiin. 

M.  flexor  digit,  min. 

2L  opponeus  digit,  rniu. 


21m.  lombricoles  -I 


M.  deltoid, 
(anterior  half) 


Mvxulo- 
euXaneous  n, 

]^  biceps  brachii 


M.brach. 
intemas 

I  Median  n, 

M.  Enpinator  longns 

M.  pronator  teres 
M.  flex,  carpi  radialls 

U.  flex,  digitor.  sublim. 

M.  flex,  pollicis  longua 
Median  n. 

II.  abductor  pollic.  brcT. 
M.  opponens  pollicis 

H.  flex.  poll.  brcv. 

ill.  adductor  pollic.  brev. 


Fig.  122. — Motor  points,  front  of  arm. 


Elect  RICA  l  Ex  a  mina  tion. 


443 


details  of  this  last  application  are  beyond  the  scope 
of  the  j)resent  work. 

The  continuous  current  must  be  of  sufficient 
intensity  to  overcome  the  resistance  of  the  body  and 
yet  have  enough  strength  left  to  stimulate  the  nerves 


Crural  n. 


M .  arUuctor  maguus 
SI.  adduct.  longas 


M,  vastus  intemus  j 


M.  teflsor  fasciae  lata»- 


JL  sartorins 


if.  quaiiriceps  femoris 
(commou  point) 

IL  rectus  femoris 


vastus  extemus 


Fig.  123.— Motor  points,  front  of  thigh. 


and  muscles.  It  must  therefore  have  an  available 
electromotive  force  of  over  40  volts.  A  battery  of 
thirty-two  Leclanche  dry  cells  is  ample  for  ordinary 
use,  as  its  electromotive  force  is  decidedly  higher 
than  this  to  start  with  and  will  continue  so  for  a 
considerable  time  if  properly  cared  for  and  neither 
left  too  long  absolutely  idle  nor  employed  to  yield  very 


444 


Nervous  System. 


heavy  currents  which  would  speedily  exhaust  the 
small  cells.  Where  the  continuous  current  from  an 
electric  light  installation  is  available  it  may  be  used, 
when  precautions  are  taken  for  the  safety  of  the  patient 
by  the  employment  of  shunts  to  reduce  the  voltage  to 
a  suitable  figure. 

Whether  battery  or  light  installation  with  regulat- 
ing board  be  used,  it  is  of  great  importance  to  have 


Udalic  n. 


TEL  Weeps,  fern.  (cap. 
long.) 

U.  biceps  fern.  (cap. 
brev.) 


Peroneal  n. 


SL.gastrocnem.  (cap. 
extern.) 


M.  soleus 


2f..flexor  hallacis  longos 


-  M.  glutens  masimns 


M.  adductor  magnna 

M.  semitendlDosns 
M.  senumeoibranQsaa 


Tibial  n. 

M.  gastrocnem.  (cap.  int.) 
M.  soleus 


M.  flexor  digitor.  conmo. 
longu3 


TiHal  n. 


Fig.  124.— Motor  points,  back  of  thigh  and  leg. 


Electrical  Examination. 


445 


efficient  accessory  apparatus  in  the  way  of  current  re- 
versers,  galvanometers,  connecting  wires,  and  electrodes. 
The  galvanometers  should  give  readings  in  milliamperes, 
not  in  unmeaning  graduations,  as  too  often  is  the  case 
in  those  supplied  with  medical  batteries. 

For  the  faradic  current  the  best  form  of  appar- 
atus is  an  induction  coil  of  the  sledge  pattern  with  a 


HL  tibial,  antic. 

34.  cxtens.  digft.  comm. 
long. 


M.  peroneus  breris 


IL  extensor  lialluois 
long. 


Hnuinteiossei  dotsales  j 


Peroneal  n. 

M.  gastrocneni.  eztenu 
M.  peroneus  longtts 


M.  soleus 


21.  flcxoz  hallncis  long; 


M.  extens.  digit,  comm. 
"breTis 


2L  abductor  digiti  mfp. 


Fig.  125. — Motor  points,  side  of  leg. 


secondary  coil  of  wire  which  should  not  be  very  fine, 
as  very  thin  wire  on  the  secondary  coil  produces  too 
great  an  effect  on  the  sensory,  and  too  little  on  the 
motor  nerves  for  most  diagnostic  purposes.     To  drive 


446  Nervous   System. 

the  coil  one  or  two  dry  Leclanch^  cells  are  sufficient. 
It  is  often  convenient  to  be  able  to  pass  from  the  con- 
tinuous to  the  faradic  current  and  vice  versd  without 
changing  the  connections  leading  to  the  patient.  This 
can  be  effected  by  a  suitable  switch. 

One  large  flat  electrode  should  be  procured,  and 
several  small  ones,  va.rying  in  size  from  a  small  spher- 
ical bulb  to  a  disc  of  metal  with  a  surface  of  about  60 
or  100  square  centimetres.  These  should  be  covered 
with  washleather,  which  can  be  renewed  at  frequent 
intervals,  and  should  be  made  to  screw  into  a  holder 
with  a  button  by  means  of  which  the  observer  can 
interrupt  the  current. 

2.  Electrodiag-iiosis.     (Figs.  120-125). 

Beg^in  with  the  faradic  current.*  It  stimu- 
lates the  nerves  directly,  the  muscles  only  indirectly 
through  their  nerve  supply.  Examine  systematically 
each  nerve  trunk  in  the  area  under  consideration,  and 
the  motor  point  of  every  muscle  supplied  by  each  of 
these  nerves.  The  motor  points  correspond  for  the 
most  part  with  the  points  of  entry  of  the  motor  nerves 
into  the  muscles  which  they  supply,  and  are  shown  in 
Figs.  120-125.  The  observer  should  try  the  current 
upon  himself  before  applying  it  to  the  patient,  both  to 
reassure  the  latter  and  to  compare  the  effects  it  pro- 
duces on  himself  with  those  elicited  in  the  patient. 
A  small  electrode — either  the  button  electrode  or  the 
disc  of  10  to  20  square  centimetres,  according  to 
circumstances — should  be  used  for  the  part  under  ex- 
amination, whilst  the  other  (or  "  indifferent ")  electrode 
should  be  a  larger  plate  placed  either  on  the  abdomen 
or  between  the  shoulders.  The  electrodes  and  the  skin 
where  the  tests  are  applied  should  be  well  soaked  with 
a  solution  of  common  salt  in  warm  water,  but  care 

*  Children,  however,  are  more  apt  to  resent  the  use  of  the 
faradic  current  than  that  of  the  galvanic,  hence  in  their  case  it  is 
often  better  to  reverse  the  usual  sequence. 


Elec  trodia  gnosis. 


447 


^L 

T  i 

Tit 

J^ 

— 

1 

/• 

^ 

/^ 

'  ..-^ 

■% 

<< 

/" 

r     - 

/- 

/ 

i' 

y 

/ 

/ 

/ 

rr 

/ 

0  mA.                S                       JO                         <3                      ^ 

Fig.    126. — Bordier's    method    of  recording    the 
electiieal  reactions  of  a  muscle,  in  health. 


must  be  taken  to  avoid  the  presence  of  any  crystals  of 
undissolved  salt  on  the  skin. 

Note  the  intensity  of  the  miniinuin  current  which 
produces  contraction  at  each  point,  and  compare  the 
effects  of  a 
similar  current 
on  the  corre- 
sponding point 
on  the  other 
side  of  the 
body. 

The  inten- 
sity of  the  cur- 
rent is  recorded 
in  terms  of  the 
distance  of  the 

secondary  from  the  primary  coil;  battery  power,  rate 
of  interruption,  and  other  adjustments  being  assumed 
to  remain  constant. 

When  the  faradic  current  has  been  employed,  pass 
to  the  g-alvanic.  Use  the  electrodes  in  exactly  the 
same  manner  as 
for  the  faradic 
examination, 
and  remember 
that  when  a 
small  electrode 
is  used,  the 
nerves  and 
muscles  that  lie 
super  ticially  be- 
neath it,  and 
are      therefore 

closer  to  it,  are  chiefly  stimulated,  since  response 
to  the  stimulus  depends  on  current  density.  Begin 
with  a  weak  current,  and  gradually  increase  its 
strength  till  the  muscle  responds  by  a  slight  contraction. 


nf 

— 

t; 

A 

y' 

^ 

r- 

*^t 

A: 

* 

** 

* 

M 

i°H 

,' 

.M 

* 
> 
/ 

r 

r^' 

y 

^x 

V  ' 

-.^ 

^A, 

|< 

X 

x' 

/ 

/ 

0 

i 

x 

.^ 

y 

X 

/ 

/ 

X 

t 

r 

O^.a.             '5                        10                     IS                    2<| 

Fig.    127. — Bordier's   method    of   recording   the 

electrical  reactionspf  a  muscle,  in  a  case  of  complete 

reaction  of  degeneration. 


448  Nervous  System. 

At  each  point  employ  first  the  cathode"^  and  then  the 
anode,  and  observe  whetiier  contraction  occurs  most 
readily  when  the  circuit  is  completed  or  when  it  is 
interrupted.  Record  the  strength  of  the  current  as 
indicated  by  the  milliamperameter  and  compare  it 
with  that  which  produces  similar  effects  at  the  cor- 
responding point  on  the  other  side. 

In  liea,ltli  the  cathodal  closing  contraction  is  the 
first  to  appear ;  in  other  words,  the  muscle  responds 
more  readily  when  the  pole  applied  to  it  is  the 
cathode,  and  when  the  electric  circuit  is  completed; 
a  decidedly  stronger  current  is  required  to  elicit 
the  anodal  closing  and  opening  contractions,  and  the 
cathodal  opening  contraction  appears  last  of  all. 
This  sequence  may  be  represented  by  the  formula 
C.C.C.  >  A.U.C.  >  A.O.C.  >  C.O.C.,  or  by  the  follow- 
ing expansion  of  it : — 

Weak  current  CC.C.  —  —  — 

Medium  current  C.C.C'  A.C.C.  —  — 

Fairly  strong  current  C.C.C."  A.C.C   A.O.C.         — 

Yery" strong  current  C.C.  Tetanus  A.C.C."  A.O.C  C.O.C. 

When  a  graphic  representation  is  desired,  the 
results  may  be  recorded  on  a  chart,  as  shown  in  Figs. 
126  and  127. 

The  contractions  in  health  are  abrupt  and  sharp. 
Except  when  the  current  is  very  strong,  contractions 
only  occur  when  the  circuit  is  made  or  broken,  not 
during  the  passage  of  a  uniform  current. 

In  disease  the  response  to  electrical  stimulation 
may  be  altered  either  quantitatively  or  qualitatively. 
By  "  quantitative  alterations  "  one  understands 
that  a  given  current  produces  a  greater  or  less  con- 
traction than  it  could  were  the  nerves  and  muscles 
in  a  normal  state.  "  Qualitative  alterations  " 
involve  either  or  both  of  two  changes— namely,  first 

*  The  cathode  or  negative  electi'ode  is  attached  to  the  zinc  rod 
in  the  cell,  the  anode  or  positive  electrode  to  the  copper  or  carbon. 


Electrodiagnosis.  449 

the  character  of  tlie  contraction,  instead  of  being 
abruf^t,  becomes  "sluggish";  and  second,  the  cathodal 
closing  contraction  is  less  readily  elicited  than  the 
anodal  contractions. 

Such  qualitati^'e  changes  depend  on  the  separation 
of  the  nerve  and  muscle  from  their  nutritive  centre. 
After  a  brief  period  the  separation  induces  degener- 
ation, and  whilst  the  degeneration  proceeds  the  nerve 
first  fails  to  respond  to  electrical  stimuli,  and  after  a 
longer  interval  the  muscle  also  becomes  insusceptible. 

It  is  during  the  time  that  elapses  between  the  insen- 
sitiveness  of  the  nerve  and  of  the  muscle,  that  the  most 
characteristic  electrical  changes  are  observed,  and  these 
are  together  known  as  "tlie  reaction  of  degeiier- 
ation."     They  may  be  summarised  as  follows  : — ■ 

T.  Faradic  current. — No  response  can  be  elicited, 
even  when  a  very  strong  current  is  employed. 

The  reason  for  this  is  that  the  Faradic  stimulus,  in  con- 
sequence of  its  brief  duration,  acts  only  on  the  nerve,  and 
since  the  degenerated  nerve  can  no  longer  transmit  stimuli  to 
the  muscle  the  latter  remains  ujiaffected. 

II.   Galvanic  current. 

(a)  Quantitative  change. — The  muscular  excitability 
is  increased,  contraction  following  the  application  of 
a  weaker  current  than  is  necessary  to  produce  it  in 
health  ("The  irritability  of  weakness"). 

(h)  Qualitative  changes. — 1.  The  contraction  is  no 
longer  sharp^  but  "sluggish." 

2.  In  most  cases  anodal  closing  contraction  is 
elicited  with  a  weaker  current  than  cathodal  closing  con- 
traction. This  phenomenon  is  less  constant  and  less  im- 
portant than  the  sluggish  character  of  the  contraction. 

The  quantitative  change  depends  partly  on  alterations  in  the 
nutrition  of  the  muscle,  and  partly  on  the  removal  of  inhihitory 
influences  ;  the  qualitative  changes  are  produced  partly  because 
the  nerve  no  longer  regulates  the  character  of  the  contraction, 
and  partly  also  as  a  result  of  changes  in  the  muscle  itseK. 

The    foregoing    description    appKes    to    a    fully 

D  D 


45©  Nervous  System. 

developed  reaction  of  degeneration.  This  is  not 
manifested  till  more  than  a  week  after  the  trophic 
influence  has  been  cut  off.  The  nerves,  however, 
begin  to  lose  their  sensitiA^eness  about  three  days 
after  the  injury,  and  gradually  become  less  and  less 
responsive.  The  muscles  behave  as  do  the  nerves  to 
Faradic  stimulation ;  to  the  galvanic  current  they  at 
first  exhibit  diminished  excitability.  After  eight  or 
ten  days  the  excitability  again  increases,  and  eventu- 
ally exceeds  that  found  in  health.  At  the  same  time 
as  the  increase  appears,  the  sluggishness  of  contraction 
and  the  abnormal  sensitiveness  to  anodal  closure 
become  manifest.  When  the  cause  which  has  led  to 
the  severance  of  the  nerve  and  muscle  from  their 
trophic  centre  cannot  be  removed,  the  muscular 
response  once  more  gradually  diminishes,  and  after 
the  lapse  of  a  considerable  period,  which  may  extend 
to  two  years  or  even  longer,  disappears  entirely. 
When  the  trophic  influence  is  timeously  re-established, 
the  reactions  of  nerve  and  muscle  progressively  return 
to  the  normal.  In  such  cases  ordinary  muscular 
power  usually  begins  to  return  some  days  before  the 
nerves  show  any  response  to  electrical  stimuli. 

It  will  be  readily  perceived  that  from  the  stand- 
point of  diagnosis,  electricity  yields  far  more  valuable 
information  when  the  disease  is  situated  in  the  lower 
motor  neuron,  thereby  severing  the  nerve  endings 
and  muscles  from  their  trophic  centres,  than  when 
the  morbid  process  occupies  a  more  central  position. 
Serious  disorder  may  be  present  in  the  higher  trophic 
realms  without  revealing  itself  by  any  change  in  the 
electrical  reactions — at  most  there  will  only  be  a 
quantitative  change  whose  detection  is  often  diflicult 
and  whose  value  is  uncertain. 

In  the  sensory  system  electrodiagnosis  is  of  less 
value,  and  is  chiefly  of  service  in  cases  where  a 
hysterical  element  is  present. 


451 


CHAPTER    X. 

Examination    of  the  Eye,   Ear,  Throat,  and 

Nose,  * 

SECTION  I.— THE  EYE. 

Note  first  any  obvious  peculiarity  about  the  eye. 
Observe  whether  there  is  any  undue  prominence  of 
one  or  both  eyes.  Prominence  of  the  eyes  occurs  in 
exophthahnic  goitre.  It  is  associated  in  that  disease 
with  the  presence  of  what  is  known  as  von  Graefe's 
sign.  Ask  the  patient  to  look  down.  If  von 
Graefe's  sign  is  present,  the  upper  lid  seems  to  lag 
behind  the  eyeball  in  its  descent,  so  that  a  large  part 
of  the  upper  portion  of  the  sclerotic  becomes  visible. 
In  paralysis  of  the  cervical  sympathetic  the  eyeball 
recedes  so  as  to  look  more  sunken  than  normal. 

Note  also  whether  the  winking  movements  are 
increased  or  diminished  in  frequency.  Infrequency 
of  the  movements  constitutes  Stellv:ag^s  sign  of  ex- 
ophthalmic goitre. 

The  occurrence  of  squint,  ptosis,  retraction  of  the 
upper  lid  and  alterations  in  the  pupil  have  already 
been  considered.  The  presence  of  any  inflamma- 
tion along  the  margins  of  the  lids  (marginal 
blepharitis)  should  always  be  noted.  It  is  often 
an  indication  of  a  strumous  constitution.  Next 
turn  your  attention  to  the  coiijwiictiva.  It 
may  be  necessary  to  examine  the  conjunctiva  lining 
the  eyelids.  In  order  to  do  this  in  the  case  of 
the   lower  lid  it  is   sufficient  to    depress    the    latter 

*  In  this  chapter  only  those  methods  of  investigation  are 
described  that  are  required  in  ordinary  medical  cases. 


45 2  Examination  of  Eye. 

firmly  with  the  thumb.  To  expose  the  inner  sur- 
face of  the  upper  lid,  place  the  right  thumb  at  the 
upper  part  of  the  upper  lid  and  push  upwards,  so  as 
to  make  the  eyelashes  stand  out  prominently.  Grasp 
the  lashes  between  the  forefinger  and  thumb  of  the 
other  hand,  and  evert  the  lid  by  rotating  it  round 
the  thumb  of  the  right  hand."^  Note  the  colour  of  the 
conjunctiva — -whether  it  is  pale,  injected,  or  jaun- 
diced. The  method  of  detecting  oedema  of  it  has 
already  been  described.  Look  at  the  cornea.  Note 
the  presence  of  any  ulceration  or  opacity  of  it. 
Small  opacities  are  described  as  ^^  nebulce.''^ ;  larger 
opacities  are  spoken  of  as  "  leticoinata.''  Try  to 
make  out  whether  the  opacity  is  really  on  the  surface 
of  the  cornea  or  deeper  down  in  its  substance.  This 
can  best  be  determined  by  looking  along  the  surface 
of  the  cornea,  as  it  were,  and  observing  whether  the 
light  is  reflected  from  it  over  the  opaque  spot,  or 
whether  it  is  dull.  If  the  former  be  the  case,  the 
opacity  is  deep-seated  ;  if  the  latter,  it  is  superficial. 
Such  superficial  opacities  point  to  former  strumous 
ulceration.  Deep-seated  opacities  are  often  due  to 
congenital  syphilis. 

*  The  following  simple  method  of  everting  the  upper  eyelid, 
so  as  to  permit  of  an  inspection  of  the  conjunctiva,  is  described  by 
Lang  in  his  book  on  "The  Methodical  Examination  of  the  Eye"  : — • 
"Whilst  the  patient  with  head  erect  turns  his  eyes  down  and 
looks  towards  the  ground,  the  observer,  who  stands  in  front,  places 
the  end  of  his  left  forefinger  on  the  right  upper  lid  just  above  the 
tarsus,  and  his  thumb  on  the  lower  lid  just  below  the  tarsus.  By 
moving  the  forefinger  a  little  upwards  the  margin  of  the  upper  lid 
is  tilted  forwards  away  from  the  globe  ;  the  thumb  is  now  made 
to  push  the  edge  of  the  lower  lid  upwards  into  the  space  between 
the  upper  lid  and  the  cornea.  The  lower  lid  thus  acts  the  part  of 
a  wedge,  and  drives  the  upj)er  lid  forwards  until  its  conjunctival 
surface  is  in  contact  with  the  thumb.  AVhen  the  whole  thickness 
of  the  upper  lid  is  between  the  finger  and  the  thumb,  the  lower 
lid  is  released  and  the  free  edge  of  the  tarsus  is  pushed  upwards 
and  backwards  by  the  thumb,  whilst  the  forefinger  presses  its 
attached  margin  downwards  and  forwards  ;  in  this  way  the  lid  is 
everted.     The  right  hand  is  employed  to  evert  the  left  lid." 


Tension  of  Eyeball.  453 

The  term  arcus  senilis  is  applied  to  a  crescentic 
opacity  which  is  sometimes  observed  towards  the 
margin  of  the  cornea.  It  usually  appears  at  the 
upper  part  of  the  cornea  first,  and  then  gradually 
extends  round.  It  occui  s  normally  in  old  people,  and 
is  sometimes  observed  also  in  the  eyes  of  younger 
persons  who  lla^  e  sclerosed  arterial  walls  and  other 
signs  of  premature  senility.  True  arcus  senilis  can 
be  recognised  by  its  leaving  a  small  strip  of  clear 
cornea  between  the  arc  and  the  sclerotic  ;  a  crescentic 
opacity  extending  inwards  from  the  sclerotic,  which 
is  sometimes  met  with,  leaves  no  such  clear  strip.  If 
arcus  senilis  be  observed  its  presence  should  always 
be  noted. 

It  is  often  of  importance  in  medical  cases  to  be 
able  to  say  whether  a  patient  is  suflering  from  iritis 
or  merely  from  conjunctivitis.  In  each  case  the  eye 
looks  red  and  injected,  but  the  characters  of  the 
injection  are  different  in  the  two  conditions.  They 
are  contrasted  in  the  foJ  lowing  table  : — 

Ciliary  Injection  (Iritis). 
Colour,  pink. 

Vessels,  straight. 
Vessels  eaimot  be  moved. 


» 


Conjimcti va I  Injection . 
Colour,  brick  red. 
Vessels  very  tortuous. 
Vessels  can  be  moved  on 


sclerotic    injection,     greatest  Injection    greatest    round 

on    lids    and    in    cul-de-sac,  ]  cornea,     diminishes    towards 

diminishes  round  cornea.  j  periphery. 

Pressure  on  lid  leaves  no  j  Pressure    on     lid     leaves 

anaemia.  '  temporary  anaemic  spot. 

In  taking  the  case,  note  specially  which  of  these 
sets  of  characters  is  present. 

The  tension  of  the  eyeball  should  next  be  tested. 
This  is  done  by  placing  the  two  forefiingers  on  the 
upper  part  of  the  sclerotic  outside  the  upper  lid 
while  the  patient  looks  downwards,  the  other 
fingers  resting;  on  his  forehead.  Then  try  for 
fluctuation.  The  normal  tension  must  be  learnt 
by   practice,   and    any   increase    or  diminution  of  it 


454  Examination  of  Eye. 

noted.  An  increased  tension  contra-indicates  the 
use  of  atropine.  Having  oljserved  these  different 
points,  one  should  next  proceed  to  what  is  termed 
oblique  focal  iBUasBBiiintioii  of  the  eyeball.  For 
this  purpose  it  is  best  to  have  the  patient  in  a  dark 
room,  a  lamp  being  placed  in  front  of  him.  By 
means  of  a  convex  lens — the  ophthalmoscope  lens 
does  very  well— the  light  is  focussed  on  the  surface 
of  the  eye.  If  necessary,  one  may  hold  another  lens 
in  the  left  hand,  and  so  magnify  the  view.  Study  in 
this  way  the  surface  of  the  cornea.  The  nature  of 
the  opacities  already  referred  to  can  now  be  observed 
more  minutely.  Look  at  the  iris.  The  outline  of  the 
pupil,  its  contractility  to  light,  the  existence  of 
synechise,  and  the  presence  or  absence  of  hippus,  can 
all  be  very  well  observed  by  this  method.  Note 
whether  any  opacity  can  be  detected  behind  the 
pupil,  and  if  so,  try  to  estimate  the  depth  at  which 
it  is  situated. 

Then  proceed  to  retinoscopy.  Use  for  this 
purpose  a  plane  or  slightly  concave  mirror,  with  an 
aperture  in  the  centre.  An  ordinary  ophthalmoscope 
mirror  does  very  well,  but  it  is  preferable  to  use  one 
of  larger  size,  say  about  two  inches  in  diameter.  The 
patient  should  be  in  a  dark  room  with  a  light  just 
above  his  head,  and  it  is  well  to  have  his  eyes 
atropised.  Sit  fully  a  yard  from  him,  and  ask  him 
to  look  far  away  over  the  top  of  your  head.  Then 
throw  the  light  into  his  eye  by  means  of  the  mirror. 
In  a  normal  eye  a  red  reflection  from  the  retina  will 
be  seen  through  the  pupil.  If  there  be  any  opacity 
of  the  refractile  media,  the  red  refl-ection  will  be 
obscured.  In  this  way  cataract  may  be  detected. 
When  commencing  it  usually  takes  the  form  of 
opaque  bands  passing  in  towards  the  centre  of  the 
pupil  like  the  spokes  of  a  wheel.  Then  tilt  the 
mirror,  Hrst  upwards  and  downwards,  then  from  side 


ASTIGMA  TISM.  45  5 

to  side.  As  one  does  so,  a  black  shadow  is  observed 
to  Hit  across  the  pupil.  Watch  the  edge  of  this 
shadow,  From  the  direction  in  which  it  moves  in- 
formation is  obtained  as  to  the  state  of  refraction  of 
the  eye.  If  the  eye  be  emmetropic,  or  if  it  be 
hypermetropic,  or  has  less  than  one  dioptre  of  myopia, 
the  edge  of  the  shadow  moves  in  the  opposite  direc- 
tion to  that  in  which  the  mirror  is  tilted  if  it  be 
concave,  but  in  the  same  direction  to  that  in  which  it 
is  tilted  if  the  mirror  be  plane.  In  myopia  of  more 
than  one  dioptre  the  edge  of  the  shadow  moves  in 
the  same  direction  as  a  concave  mirror,  but  in  the 
opposite  direction  to  one  which  is  plane.  In  a  normal 
eye  the  shadow  moves  very  rapidly,  and  has  a  straight 
and  sharply-de6ned  edge."^  The  more  abnormal  the 
patient's  refraction,  the  more  slowly  does  the  shadow 
move,  and  the  more  crescentic  and  the  less  well 
defined  is  its  margin. 

If  the  edge  of  the  shadow  moves  differently  in 
opposite  meridians,  the  eye  is  astig^matic.  If  one 
meridian  is  normal  the  astigmatism  is  simple,  and 
may  either  be  of  the  myopic  or  of  the  hypermetropic 
variety,  according  to  the  nature  of  the  refraction  in 
the  abnormal  meridian.  If  both  meridians  are 
abnormal,  the  error  of  refraction  being  the  same  in 
kind  in  each,  but  unequal  in  degree,  cotiwound  astig- 
matism is  present.  It  may'  also  be  either  of  the 
myopic  or  of  the  hypermetropic  variety,  according  to 
the  nature  of  the  refraction.  If  one  meridian  is 
myopic,  the  other  hypermetropic,  the  condition  is  one 
of  mixed  astigmatism. 

In  regular  astigmatism  the  directions  of  greatest 
and  least  refraction  are  at  right  angles  to  each  other, 
and  usually  fall  exactly  in  the  vertical  and  horizontal 

*  The  edge  of  the  shadow  is,  of  course,  straight  only  when  the 
soiTixe  of  li^ht  lias  a  straight  edge.  This  is  so  in  an  Argand 
burner,  but  not  in  an  electric  lamp. 


456  Examination  of  Eye. 

meridians,  the  meridian  of  greatest  curvature  being 
most  frequently  the  vertical.  Sometimes,  howeA^'er, 
the  directions  of  greatest  and  least  refraction  are  in 
the  oblique  meridians. 

In  irregular  astigmatism  the  directions  of  greatest 
and  least  refraction  are  not  at  right  angles.  This 
occurs  comparatively  rarely. 

For  the  optical  explanation  of  these  facts,  and 
for  the  more  detailed  description  of  their  significance, 
the  reader  is  referred  to  special  works  on  ophthal- 
mology. We  would  only  remark  here  that  retinoscojDy 
affords  the  simplest  and  readiest  method  of  arriving 
at  an  idea  of  the  state  of  a  patient's  refraction."^  In 
examining  many  medical  cases  such  information  is 
well  worth  obtaining,  as  errors  of  refraction  have 
been  found  to  be  the  reflex  cause  of  many  nervous 
symptoms,  e.g.  of  headache,  vomiting,  etc. 

The  fundus  oculi  remains  still  to  be  examined, 
and  for  this  one  must  have  recourse  to  the  use  of  the 
oplitlialiiioseope.  Many  patterns  of  this  instru- 
ment are  sold.  The  essential  points  are  that  there 
should  be  two  mirrors — a  larger  one  for  use  in  the 
indirect  method  of  examination,  and  a  smaller  angled 
one  for  direct  examination  of  the  fundus.  It  is  also 
important  to  be  able  to  bring  a  series  of  small  lenses 

*  Sometimes  a  patient  comes  before  one  wearing  glasses,  and 
it  may  be  imj)ortant  to  know  what  the  refraction  of  these  is.  In 
order  to  discover  this,  hold  the  ^lass  in  front  of  the  eye  and  look 
at  an  object  through  it.  Then  move  the  glass  from  side  to  side, 
and  watch  the  object.  If  the  latter  seems  to  move  in  the  opposite 
direction  to  the  glass,  the  latter  is  convex  ;  if  in  the  same  direction, 
it  is  concave. 

The  strength  of  the  glass  maj^  be  approximately  determined  by 
bringing  the  small  lenses  of  the  ophthalmoscope  behind  it  until 
one  finds  that  which  abolishes  the  apparent  movement  of  the 
object  looked  at. 

In  order  to  tell  whether  the  glass  is  spherical  or  cylindrical, 
look  at  a  straight  object,  e.c/.  a  window  bar,  through  the  glass, 
and  then  slowly  twist  the  latter  round.  If  the  glass  is  cylindrical, 
the  object  looked  at  will  aijpear  to  take  up  an  oblique  i^osition. 
Patients  who  use  cylindrical  glasses  are  astigmatic. 


Oph  tha  l  mo  scop  y.  45  7 

of  different  refraction  behind  the  eyehole  in  the 
mirror.  We  would  add,  also,  that  the  ordinary  glass 
lens  sup])lied  with  the  instrument  is  inconveniently 
small.  It  is  mucli  l^etter  to  have  one  of  about  two 
inches  in  diameter.  This  can  easily  be  obtained  at  a 
slight  additional  cost,  and,  if  necessary,  can  be 
carried  sej^arately  in  a  small  bag  of  chamois  leather. 

There  are  two  methods  of  using  the  ophthalmo- 
scope— the  indirect  and  the  direct.  "We  shall  describe 
the  former  first, 

1.  Indirect  opiillialaiioscopy. — It  is  best  to 
have  the  room  darkened ;  at  any  rate,  bright  sunlight 
should  be  excluded.  If  the  patient  is  in  bed  this  may 
be  effected  by  placing  an  umbrella  over  him.  The 
patient  (if  he  is  able)  sits  in  a  chair  with  his  head 
slightly  inclined  forwards,  and  the  observer  in  another, 
about  two  feet  from  that  of  the  patient,  and  directly 
opposite  to  the  latter.  A  light — an  ordinary  oil 
lamp,  or,  preferably,  an  Argand  burner — is  placed 
close  to  the  patient  and  on  a  level  with  his  left 
shoulder.  The  observer  should  sit  rather  obliquel}^, 
his  left  shoulder  being  turned  well  round  towards 
the  patient.  The  ophthalmoscope  is  held  in  the 
right  hand,  the  larger  mirror  being  opposite  the 
eye-hole.  If  the  observer  is  not  emmetropic,  he 
corrects  his  own  error  of  refraction  by  means  of  the 
small  lenses  behind  the  mirror;  light  is  then  reflected 
into  the  patient's  eye  from  the  lamp.  A  red 
reflection  from  the  retina  should  fill  up  the  entire 
pupil  unless  there  be  any  opacity  of  the  media,  as 
already  mentioned.  Xo  details  of  the  fundus  should 
yet  be  visible.  If  any  blood-vessels  be  seen,  one 
can  be  sure  that  the  patient's  refraction  is  abnormal. 
If  these  seem  to  move  in  the  same  direction  as  the 
head  of  the  observer,  the  patient  is  hypermetropic; 
if  in  the  opposite  direction,  he  is  myopic.  Having 
got   the   fundus   fully  illuminated,    one   proceeds  to 


45 8  Examination  of  Eye. 

interpose  the  convex  lens  of  the  ophthalmoscope.  Hold 
it  between  the  finger  and  thumb  of  the  left  hand,  so 
that  it  rests  opposite  the  joints  between  the  first 
and  second  phalanges  of  the  index.  The  finger  should 
not  be  at  all  flexed.  The  fore-arm  should  be  kept 
vertical,  the  hand  drooping  from  the  wrist,  and  the 
little  finger  supported  on  the  patient's  forehead.  This 
is  the  position  demanding  the  least  muscular  eftbrt, 
and  therefore  the  least  fatiguing  to  the  observer.  The 
ordinary  ophthalmoscopic  lens  is  of  about  +  15 
dioptres  strength,  and  therefore  requires  to  be  held 
about  2^  inches  from  the  patient's  eye."^ 

The  exact  point  at  which  it  should  be  held  is 
arrived  at  by  moving  the  lens  backwards  and  forwards 
till  a  clear  image  is  obtained. 

A  larger  image  of  the  fundus  can  be  obtained  })y 
using  a  convex  lens  of  about  +10  D  (4  inches  focus) 
and  magnifying  the  image  by  means  of  a  -f  2  D  lens 
placed  behind  the  mirror.  In  many  ways  this  is 
preferable  to  the  ordinary  method.  Having  got  the 
fundus  into  focus,  one  wishes  to  look  at  three  i)arts 
of  it — (1)  at  the  optic  disc,  (2)  at  the  macular  region, 
(3)  at  the  periphery.  In  order  to  bring  the  disc  into 
view,  the  patient  must  be  made  to  turn  his  eye  some- 
what inwards.  If  the  left  eye  is  being  examined,  ask 
him  to  look  at  the  tip  of  your  left  ear ;  if  the  right  is 
being  examined,  ask  him  to  look  at  the  tip  of  the  little 

*A  lens  of  1  dioptre  (1 D)  strength  has  a  focal  distance  of  1  metre 
(40  inches);  a  lens  of  2  D  has  a  focal  distance  of  20  inches,  and  so  on. 
To  signify  a  convex  lens  the  sign  +  is  used,  thus  :  +  2  D  means  a 
convex  lens  of  2  dioptres  ;  —  2  D  means  a  coucave  lens  of  2  dioptres, 
A  lens  wliich  is  curved  equally  in  every  direction — i.e.  which  isjiart 
of  a  sphere— is  called  spherical.  It  may  be  either  convex  or  concave. 
A  concave  spherical  lens  of  one  diojitre  strength  is  indicated  thus  : 
— 1  D  spher. 

A  cylindrical  lens  is  part  of  a  cylinder,  and  is  therefore  curved 
in  one  direction  only.  The  direction  corresponding  to  the  axis  of 
the  cjdinder  is  uncurved,  and  is  spoken  of  as  the  axis  of  the  lens. 
A  convex  cylindrical  lens  of  one  dioi^tre  strength  is  written  +  1  D 
cyl.     Cylindrical  lenses  are  required  in  astigmatism. 


Oph  tha  l  mo  scop  y.  459 

fiiiijer  of  the  rii^^ht  hand,  wliich  is  stretclied  out  for  tlie 
purpose  beyond  the  handle  of  the  ophthahnoscope. 

In  order  to  see  the  macuhxr  region  ask  the  patient 
to  bring  the  eye  slowly  back  from  the  above  position 
toM-ards  the  centre  of  your  forehead.  The  macular 
reo;ion  is  reached  at  about  two  discs'  breadth  from  the 
margin  of  the  disc.  Attempts  to  look  straight  at  the 
macula  in  this  way  are  sometimes  baffled  by  the  great 
contraction  of  the  pupil  which  results,  and  by  the 
reflection  of  light  from  the  surface  of  the  cornea. 
When  this  is  the  case  it  is  better  to  ask  the  patient  to 
look  not  straight  at  the  forehead,  but  a  little  to  one 
side.  The  observer  must  then  move  his  head  till  a 
view  of  the  macular  region  is  obtained. 

The  periphery  of  the  fundus  ls  seen  by  asking  the 
patient  to  look  first  to  his  extreme  right  and  left,  then 
up  to  tlie  ceiling,  then  downwards. 

If,  on  gradually  withdrawing  the  lens,  the  image 
of  the  fundus  appears  to  become  larger,  there  is 
myopia  present.  If  it  becomes  smaller^  there  is 
liypennetropia.  If  it  alters  in  one  direction  and  not 
in  others,  there  is  simple  astigmatism  ;  if  it  alters  in 
one  direction  more  than  others,  the  astigmatism  is 
compound. 

If,  on  moving  the  lens  from  side  to  side,  one 
part  of  the  fundus  seems  to  move  over  the  rest 
("parallactic  movement"),  that  part  is  at  a  higher 
level  than  its  surroundings.  Thus,  if  the  disc  be 
excavated,  its  margin  will  appear  to  move  over  the 
deeper  part. 

The  examination  of  the  fundus,  and  especially  of 
its  peripheral  region,  is  greatly  facilitated  by  a  prelim- 
inary dilatation  of  the  pupil.  The  best  way  of  effect- 
ing this  is  to  apply  a  2%  homatropine  and  cocaine 
ointment  to  the  eye  about  half  an  hour  before  ex- 
amining it.  The  effect  may  be  afterwards  counteracted 
by  instilling  a  drop  of  eserine  solution  (1%). 


460  Examination  of  Eye. 

If  the  patient  be  unable  to  leave  bed,  indirect 
ophthalmoscopy  may  easily  be  carried  out  by  the  above 
method,  provided  he  is  able  to  be  propped  up.  If 
that  is  impossible,  place  the  lamp  on  the  pillow  above 
his  head,  and  carry  out  the  rest  of  the  procedure 
as  above. 

2.  Direct  ophtiialmoscopy.— The  patient  is 
placed  as  before,  but  with  the  light  a  little  behind 
and  above  the  shoulder  corresponding  to  the  eye  under 
examination.  The  observer  sits  quite  close  to  the 
patient,  so  that  his  eye  can  be  advanced  to  within  two 
inches  of  that  of  the  latter.  In  examining  the  left  eye 
of  the  patient,  use  your  own  left  eye,  and  for  his  right 
use  your  right.  Tilt  the  patient's  head  and  your  own 
in  opposite  directions,  so  as  to  avoid  breathing  one 
another's  breath.  Arrange  the  ophthalmoscope  with 
the  small  oblique  mirror  opposite  the  eye-hole,  and  its 
surface  directed  towards  the  light.  The  apex  of  the 
wedge  formed  by  the  tilt  of  the  mirror  should  be 
directed  towards  the  root  of  the  observer's  nose,  when 
the  instrument  is  held  flat  against  his  cheek.  If 
there  is  difficulty  in  getting  proper  illumination  of 
the  fundus,  move  the  source  of  light  about  until  the 
bright  red  reflection  is  seen  through  the  pupil.  Ask  the 
patient  to  look  over  your  shoulder  at  a  distant  object, 
and  try  to  relax  your  own  accommodation  entirely. 
This  is  the  real  point  of  difficulty  in  the  direct 
method.  As  one  is  desirous  of  seeing  clearly  the  fundus 
of  the  patient,  and  as  that  is  so  near,  one  almost 
instinctively  accommodates  his  own  eye  for  a  near 
object.  With  practice,  however,  this  difficulty  can  be 
overcome.  It  sometimes  helps  one  to  achieve  the 
desired  result  if  he  tries  to  think  in  a  dreamy  way  of 
some  distant  object,  and  to  picture  it  to  himself.  If 
it  is  found  impossible  at  first  to  relax  one's  accom- 
modation completely,  it  may  be  nullified  by  the  use  of 
a  —  2-3  D  lens  behind  the  mirror. 


Ophthalmoscopy.  461 

When  the  fun(Uis  has  been  brought  into  clear 
focus,  its  diiferent  regions  must  be  systematically 
studied,  just  as  in  the  use  of  the  indirect  method.  In 
order  to  see  the  disc  by  the  direct  method,  look  back- 
wards and  inwards  obliquely  into  the  eye,  telling  the 
patient  meanwhile  to  look  straight  in  front  of  him. 

In  the  case  of  a  patient  who  is  unable  to  rise  from 
bed,  the  direct  method  may  be  applied  in  one  of 
several  ways. 

(1)  The  observer  kneels  beside  the  bed  at  right 
angles  to  the  patient,  the  light  being  placed  on  the 
pillow  at  the  opposite  side  of  the  head  of  the  latter. 
(2)  The  observer  places  himself  at  the  top  of  the  bed, 
so  as  to  look  down,  as  it  were,  on  the  patient's  eyes, 
the  light  being  placed  on  the  opposite  side  of  the 
head  from  the  eye  to  be  examined.  (3)  If  the  patient 
be  a  child,  place  him  across  the  bed,  and  kneel  at  the 
patient's  head,  the  light  being  held  at  the  opposite 
side  from  the  eye  under  examination. 

The  images  furnished  by  the  two  methods  of 
ophthalmoscopy  differ.  In  the  indirect  method  the 
image  is  inverted,  so  that  what  seems  to  be  the  upper 
part  of  the  fundus  is  really  the  lower,  and  the  inner 
(nasal)  side  appears  to  be  the  outer,  and  vice  versa. 
The  image,  however,  embraces  a  large  part  of  the 
fundus  at  one  time,  so  that  one  gets,  as  it  were, 
a  bird's  eye  view  of  it.  This  method  is,  therefore, 
well  suited  for  ordinary  diagnostic  purposes  in 
medical  cases. 

The  image  obtained  by  the  direct  method  is  an 
upright  image,  and  therefore  the  different  parts  of 
the  fundus  are  seen  in  their  proper  positions.  The 
image  embraces  only  a  small  part  of  the  fundus 
at  one  time,  but  gives  a  magnified  view  of  it.  It  is, 
therefore,  well  suited  for  the  minute  study  of  patho- 
logical changes  in  the  fundus. 

The  image  obtained  by  the  modification  of  the 


462  Examination  of  Eye. 

indirect  method  already  described  {i.e.  by  interposing 
a  weak  convex  lens,  and  magnifying  the  image  by  a 
+  2  D  lens  behind  the  mirror)  is  intermediate 
between  the  images  obtained  by  the  ordinary  indirect 
and  by  the  direct  method.  It  is  an  inverted  image, 
pretty  highly  magnilied,  and  shows  also  a  fairly  large 
part  of  the  fundus  at  one  time. 

We  have  said  that  the  optic  disc,  the  macular 
region,  and  the  periphery  of  the  fundus  must  be 
studied  in  detail  in  each  case.  We  may  now  pass 
to  a  consideration  of  the  special  points  to  be  taken 
note  of  in  each  of  these  regions. 

1.   Note  as  regards  the  optic  disc — 

id)  Its  sliaiie.  Normally  this  is  circular.  Some- 
times it  is  oval.  If  there  be  astigmatism  present, 
the  disc  will  appear  to  be  oval,  although  it  is  really 
circular.  This  apparent  oval  shape  may  be  dis- 
tinguished from  that  which  is  real  by  moving  the 
lens  backwards  and  forwards.  If  the  disc  be  really 
oval,  it  remains  unaltered  ;  if  it  is  only  apparently 
oval,  its  shape  will  be  found  to  vary  with  the  position 
of  the  lens. 

(6)  Its  colour.  The  normal  disc  is  of  a  rosy  tint, 
but  distinctly  paler  than  the  rest  of  the  fundus. 
The  nasal  side  is  normally  rather  redder  than  the 
other. 

In  atrophy  of  the  optic  nerve,  the  disc  becomes 
very  pale,  and  may  even  be  dead  white  or  greyish  in 
tint.  In  active  hypersemia  of  the  disc  its  colour 
approaches  in  intensity  to  that  of  the  rest  of  the 
fundus.  Such  active  hyperpemia  is  often  present 
in  high  degrees  of  hypermetropia.  In  passive 
hyper^emia  of  the  disc  the  veins  are  alone  affected 
(p.  464),  and  the  general  tint  is  not  altered. 

(c)  The  presence  or  absence  of  a  'physiological  jyit-, 
and  its  size.  Do  not  mistake  the  pallor  produced  by 
a  very  large  pit  for  the  pallor  of  optic  atrophy. 


Ophthalmoscopy.  463 

(0?)  The  character  of  the  vessels.  The  arteries  are 
normally  distinguished  from  the  veins  by  the  following 
characters  : — They  are  only  |-^  the  breadth  of  the 
veins,  and  they  are  not  so  dark  in  colour.  They  have 
a  broader,  better  defined,  and  more  continuous  light 
stripe  along  their  centres 

Normally,  the  arteries  do  not  pulsate.  They  may 
be  observed  to  do  so  in  cases  of  aortic  re^uro-itation, 
and  in  increased  intra-ocular  tension.  The  veins  some- 
times pulsate,  even  in  normal  eyes,  either  owing  to 
the  twisting  of  the  arteries  round  them  at  points,  or 
to  high  intra-ocular  tension. 

(e)  The  edge  of  the  disc.  It  should  be  clear  and 
well  defined — especially  at  its  outer  side.  As  the 
vessels  run  across  it,  they  should  not  be  observed  to 
tumble  over  at  all.  This  "tumbling  over,"  if  present, 
is  best  evinced  by  the  sudden  disappearance  of  the 
central  light  strijDe  on  the  vessel. 

( /")  The  surroundings  of  the  disc.  This  part  of 
the  fundus  should  be  carefully  searched  if  one  is  on 
the  outlook  for  the  presence  of  haemorrhages  or 
tubercles,  as  both  of  these  are  more  often  encountered 
in  the  immediate  neighbourhood  of  the  disc  than  at 
other  parts  of  the  fundus. 

Tubercles  will  be  recognised  as  roundish,  ill-defined, 
yellowish  bodies,  usually  about  half  as  large  as  the 
disc.  Hcemorrhages  occur  as  bright  or  dark-red 
blotches,  with  flame-like  margins. 

2.  The  inaciilar  reg'ioii  is  situated,  as  we  have 
said,  about  two  discs'  breadth  from  the  outer  edcre  of 
the  disc.  It  is  recognised  by  being  rather  darker  in 
colour  than  the  rest  of  the  fundus,  by  being  very 
devoid  of  blood-vessels,  and  frequently  by  being  sur- 
rounded with  a  halo  of  reflected  light,  producing  a  shot- 
silk  appearance.  The  macula  itself  is  in  the  centre  of 
the  region,  and  is  rather  pale  in  colour,  and  often 
glitters  somewhat. 


464  Examination  of  Eve. 

Changes  in  the  macular  region  are  important,  in 
that  they  interfere  more  with  vision  than  similar 
changes  in  any  other  part  of  the  fundus.  In  cases 
of  albuminuric  retinitis,  a  circle  of  white  s[)ots 
may  often  be  observed  arranged  around  the  macula 
(p.  467). 

3.  Periphery. — Inspection  of  the  periphery  of  the 
retina  is  important,  as  it  is  here  that  some  changes 
— such,  for  example,  as  disseminated  choroiditis  and 
retinitis  pigmentosa — -are  most  early  to  be  detected. 

The  following  is  a  brief  description  of  the  chief 
changes  met  with,  in  the  fundus,  which  are  of  im- 
portance from  a  medical  point  of  view  : — • 

Optic  neuritis. — -In  medical  cases  this  is  usually 
bilateral  (double  optic  neuritis).  It  begins  as  a  mere 
passive  congestion  of  the  disc,  with  slight  oedema.  At 
this  stage  the  veins  are  fuller  than  normal;  on  indirect 
examination  the  edge  of  the  disc  seems  clear  enough, 
but  on  closer  inspection  by  the  direct  method  it 
is  seen  to  be  slightly  fiulfy-looking.  The  change  in 
the  edge  of  the  disc  usually  begins  at  its  upper  and 
lower  margins.  These  parts  should  therefore  always 
be  most  carefully  inspected. 

As  the  process  progresses,  it  passes  into  true 
neuritis  or  papillitis.  The  disc  is  now  distinctly 
swollen.  This  is  best  recognised  by  the  fact  that, 
on  direct  examination,  one  requires  (provided  his 
accommodation  is  fully  relaxed)  the  aid  of  a 
convex  lens  behind  the  mirror  in  order  to  bring  the 
vessels  on  the  disc  clearly  into  focus.  The  veins  are 
still  larger  than  before,  and  distinctly  tortuous. 
Pathological  tortuosity  of  the  veins  occurs  at  right 
angles  to  the  plane  of  the  retina.  Tortuosity  in  the 
same  plane  as  the  retina  may  be  quite  normal.  Often 
the  veins  can  be  observed  to  tumble,  as  it  were, 
over  the  edge  of  the  swollen  disc.  The  arteries  are 
smaller  than  normal,  and  may  be  partly  obscured  by 


Ophthalmoscopy.  465 

the  presence  of  exudation.  The  edge  of  the  disc  is 
no  longer  clear,  even  on  indirect  examination,  l^ut 
fa  les  off  into  the  surrounding  retina  Small  haemor- 
rhages may  be  observed  on  or  near  the  disc. 

It  is  often  important  to  decide  whether  the  pajjil- 
litis  is  advancing  or  not.  One  ought  not  to  form  an 
opinion  on  this  point  unless  he  has  already  examined 
the  discs  on  a  previous  occasion.  The  best  criterion 
is  the  degree  of  swelling  of  the  disc.  In  order  to 
estimate  this,  use  the  direct  method,  and  be  sure  that 
your  own  accommodation  is  thoroughly  lelaxed. 
Notice  first  wl] ether  the  retina  can  be  seen  quite 
clearly  without  the  aid  of  a  lens.  If  the  eye  is  emme- 
tropic, one  ought  to  be  able  to  do  so.  If  the  le- 
fraction  is  abnormal,  place  behind  the  mirror  the  lens 
which  is  required  to  bring  the  vessels  on  the  retina 
clearly  into  focus.  Then  look  at  the  vessels  on  the 
disc.  Owing  to  the  swelling  of  the  latter,  the  vessels 
are  nearer  the  observer's  eye  than  they  should  be, 
and  a  +  lens  must  therefore  be  brought  behind  the 
mirror  in  order  to  enable  one  to  focus  them  clearly. 
The  strength  of  the  lens  required  is  the  gauge  of  the 
amount  of  swelling  which  is  present  in  the  disc. 
Suppose,  for  example,  that  one  requires  to  use  +  1  D 
in  order  to  focus  the  retina  clearly  {i.e.  the  patient 
has  1  D  of  hypermetropia),  but  that  in  order  to  focus 
the  vessels  on  the  disc  one  requires  to  make  use  of  a 
+  6  D,  then  there  is  obviously  +  5  D  of  swelling. 
Roughly  speaking,  every  3  D  =:=  1  millimetre  of  swel- 
ling. In  this  way,  one  can  estimate  the  amount  of 
swelling  from  day  to  day,  and  so  determine  wdiether 
the  neuritis  is  advancing  or  receding.  The  above 
method,  it  is  obvious,  requires  a  considerable  amount 
of  practice,  and  it  is  absolutely  essential  for  success 
that  the  observer  should  be  able  thoroughly  to  relax 
his  own  accommodation. 

Those   who   are  unable  thoroughly  to  relax  their 

E    E 


466  Examination  of  Eye. 

accommodation  may  use  the  following  method  instead 
of  the  above  : — Bring  behind  the  mirror  the  weakest 
—  or  strongest  +  If^ns  with  which  («)  the  vessels 
on  the  fundus  can  still  be  clearly  defined;  do  the 
same  for  (6)  the  vessels  on  the  top  of  the  disc.     Then 

=  the  height  of  the  disc  in  millimetres. 

3  "" 

Optic  neuritis  is  present  in  most  cases  of  cerebral 
tumour  at  some  period  of  the  disease.  It  occurs  also 
in  about  50  per  cent,  of  cases  of  tubercular  meningitis, 
although  it  is  often  late  in  making  its  appearance.  It 
is  very  uncommon  to  meet  with  it  in  the  simple  basal 
meningitis  of  infants,  and  in  ordinary  acute  menin- 
gitis. It  is  also  infrequent  in  cerebral  abscess,  and 
is  not  met'  with  in  cases  of  cerebral  haemorrhage,  or 
thrombosis.  On  the  other  hand,  it  is  not  infrequent 
in  other  than  intracranial  diseases,  and  especially  in 
Bright's  disease  (most  commonly  in  the  form  which  is 
associated  with  cirrhosis  of  the  kidney  and  thickening 
of  the  blood-vessels).  It  is  also  met  with  in  lead 
poisonings  and  in  some  cases  of  anaemia. 

Optic  atrophy. — We  have  already  mentioned  that 
the  most  striking  change  in  the  fundus  in  this  con- 
dition is  the  pallor  of  the  disc  and  the  smallness  of 
the  arteries  on  it.  The  atrophy  may  be  («)  primary 
{e.g.  in  locomotor  ataxy) — this  is  sometimes  called 
simple  atrophy  ;  or  (6)  it  may  be  post-neuritic 
atrophy  ;  or  (c)  it  may  follow  degenerative  changes  in 
the  retina.  It  is  not  always  easy  to  say  from  a  mere 
inspection  of  the  fundus  which  variety  it  is  that  one 
has  to  deal  with,  and  the  longer  the  process  has  gone 
on  the  more  difficult  does  the  diagnosis  become.  Look 
at  the  edges  of  the  disc.  If  they  are  indistinct, 
especially  if  white  streaks  can  be  seen  radiating  out 
from  them  and  passing  along  the  vessels  into  the 
retina,  then  one  can  be  pretty  sure  that  the  atrophy 
is  not  primary  but  is  post-neuritic  in  origin.       If  the 


Changes  in  Fundus.  467 

atrophy  is  secondary  to  changes  in  the  retina  the 
disc  looks  like  a  bit  of  dirty  parchment,  and  pig- 
mentary changes  will  be  seen  in  the  retina.  In 
atrophy  without  previous  optic  neuritis  the  thinning 
of  the  nei've  fibres  renders  very  visible  the  fibres  of 
the  lamina  cribosa,  and  the  disc  acquires  a  "mottled" 
appearance.  The  presence  of  such  mottling  should 
always  be  carefully  noted. 

Albuminuric  retinitis.  — •  This  condition  of  the 
fundus  is  met  with  in  some  cases  of  Bright's  disease, 
especially  in  the  very  chronic  forms.  The  changes 
consist  in  (1)  the  presence  of  optic  neuritis  with 
marked  fulness  of  the  veins  ;  (2)  the  occurrence  of 
haemorrhages  on  or  near  the  disc  ;  (3)  the  development 
of  white  shining  spots  around  the  disc  at  a  distance 
of  about  three  discs'  breadth  from  it,  and  of  similar 
but  much  smaller  spots  arranged  in  a  stellate  form 
around  the  macular  region.  Any  one  of  these  sets 
of  changes  may  be  present  without  the  others.  The 
presence  of  these  changes  should  be  looked  for  in 
every  case  of  chronic  renal  disease. 

Tubercle  of  the  choroid  and  hcemorrhages  in  the 
retina  have  already  been  mentioned,  and  their 
commonest  sites  pointed  out.  Tubercles  may  be 
looked  for  in  cases  of  suspected  acute  miliary 
tuberculosis  and  tubercular  meningitis.  As  they 
only  appear  very  late  in  the  affection,  however,  they 
are  more  of  pathological  interest  than  of  diagnostic 
importance. 

Hetinal  hsemorrhages  may  occur  in  any  form  of 
profound  anaemia,  but  especially  in  pernicious  anaemia 
and  leucocythsemia.     They  also  occur  in  purpura. 

Embolism  of  the  central  artery  of  the  retina  may 
occur  in  cases  of  endocarditis.  The  appearance  of 
the  fundus  is  characteristic.  Look  at  the  macular 
region  especially.  There  is  present  at  it  a  peculiar 
round  cherry-red  spot.     The  disc  itself  is  pale  and  its 


468  Examination  of  Ear. 

arteries  are  empty.     The  retina  as  a  whole  is  some- 
what milky-looking  from  the  presence  of  CEclema. 

Disseminated  choroiditis. — This  is  often  an  im- 
portant sign  of  previous  syphilis.  The  changes 
observed  are  the  presence  of  small  white  patches  of 
various  shapes  and  sizes,  and  disturbance  of  the  pig- 
ment around  them.  These  can  be  recognised  as  being 
situated  in  the  choroid  by  the  fact  that  the  retinal 
vessels  pass  over  them.  In  congenital  syphilitic  choroi- 
ditis there  is  often  a  marked  heaping  up  of  pigment 
around  the  patches,  which  are  mostly  circular  in  shape. 

SECTION   II.— THE   EAR. 

Examine  first  the  external  ear.  Note  any  pecu- 
liarity of  shape,  observe  the  presence  of  any  tumour  or 
swelling,  or  the  existence  of  any  skin  eruption  upon 
it.  Observe  whether  there  is  any  discharge  from  the 
meatus,  and  if  so,  make  a  note  of  its  character  and 
odour.  Note  also  whether  there  is  any  redness, 
tenderness,  or  swelling  over  the  mastoid. 

The  meatus  and  membrane  must  next  be 
inspected.  Daylight  is  best  for  the  purpose.  Place 
the  patient  with  the  ear  to  be  examined  turned  away 
from  the  light.  Use  a  handled-mirror  about  three 
inches  in  diameter,  of  a  focal  distance  of  about 
six  inches,  and  with  a  perforation  in  the  centre.  In 
order  to  catch  the  light  properly  the  surface  of  the 
mirror  should  be  turned  slightly  upwards.  By  this 
means  the  external  auditory  meatus  can  be  inspected. 
Note  the  presence  of  any  foreign  body,  of  an  ac- 
cumulation of  wax,  of  any  eczematous  eruption  or 
furuncles,  or  any  other  abnormality,  as  the  presence 
of  such  may  contra-indicate  the  use  of  the  speculum. 

Various  forms  of  aspergillus  may  grow  in  the 
external  auditory  meatus  and  set  up.  an  Otitis.  The 
colour  of  the  inspissated  discharge  depends  upon  that 
of  the  aspergillus,  being  black  where  A.  niger  is  the 


Aural  Speculum.  469 

fungus.  The  structure  of  the  growth  can  be  seen  if 
some  of  the  debris  is  mixed  with  a  little  liquor  potassse 
and  glycerine  and  examined  under  the  microscope. 

In  order  to  see  the  membrane,  a  speciiliim  must 
Ije  employed.  A  metal  speculum  is  best,  unless  one  is 
wishing  to  make  use  of  caustic  applications,  in  which 
case  it  is  better  to  use  a  vulcanite  instrument. 
Choose  a  size  of  speculum  appropriate  to  the  ear 
under  examination,  warm  it  slightly,  and  introduce  it 
so  that  the  long  diameter  of  its  smaller  end  is  placed 
almost  vertically,  but  with  a  slight  inclination  from 
above  downwards  and  forwards.  Take  care  not  to 
introduce  it  too  far — not  beyond  the  cartilaginous 
part  of  the  meatus.  There  is,  of  course,  no  use  in 
attempting  to  dilate  the  osseous  part.  Having  intro- 
duced the  speculum,  hold  it  in  position  by  means  of 
the  forefinger  and  thumb  of  one  hand,  while  the 
pinna  is  gi'asped  between  the  ring  and  middle  finger 
of  the  same  hand,  the  mirror  being  held  in  the  other. 
The  pinna  should  be  pulled  gently  upwards  and  back- 
w^ards,  so  as  to  straighten  the  meatus  as  much  as 
possible.  The  mirror  is  held  with  its  surface  look- 
ing slightly  upwards  as  before,  and  the  membrane  can 
then  usually  be  seen  on  looking  down  the  speculum. 
If  the  ^T.ew  be  obstructed  by  the  presence  of  impacted 
wax,  the  latter  should  be  removed  by  being  first 
softened  w4th  warm  almond  or  oKve  oil  or  soda 
solution  (two  teaspoonfuls  of  the  bicarbonate  to  the 
pint),  and  then  syringed  out. 

The  student  will  find  that  it  is  not  very  easy  at 
first  to  hold  the  speculum  properly  and  at  the  same 
time  to  pull  the  pinna  upwards  and  backwards.  It 
is  therefore  better,  if  one  can,  to  have  the  mirror 
attached  to  the  forehead  by  means  of  a  spectacle 
frame.  This  leaves  both  hands  free  to  manipulate 
the  ear  and  speculum,  or  to  make  applications  by 
means  of  the  probe,  etc. 


470 


Examination  of  Ear. 


If  an  ear  miiTor  be  not  at  hand,  the  large  mirror 
of  an  ophthalmoscope  can  be  made  to  serve  the  purpose. 
The  lens  of  the  ophthalmoscope  can  also  be  held  close 
to  the  speculum,  and  so  a  magnihed  view  of  the  mem- 
brane is   obtained.     This  is  especially  serviceable   in 


examining  the  ears  of  children. 


The   first 
membrane    (Fig.    128) 

and    translucency.       A 


thing  noticeable    about    the    normal 


is    its    bluish-grey    colour 
small    white     knuckle-like 


Fig.  128.— Normal  tympanic  membrane.    Twice  natural  size. 

{After  PoUtzer.) 

A,  handle  of  malleus ;  b,  umbo  ;  c,  short  process  of  malleus  ;  d,  posterior  fold  ; 

E,  triangle  of  light ;  f,  merabrana  flaccida  ;  G,  long  process  of  incus. 

prominence  may  be  observed  towards  the  middle 
of  its  upper  part.  That  is  the  short  process  of 
the  malleus.  Passing  downwards  and  backwards 
from  it  the  long  process  of  the  malleus  may  be 
noticed,  which  ends  in  the  umbo  near  the  centre 
of  the  membrane.  Passing  forwards  and  back- 
wards from  the  short  process  of  the  malleus  one 
notices  the  anterior  and  posterior  folds  of  the  mem- 
brane. A  triangular  light  portion  of  the  membrane 
usually  catches  the  eye,  the  apex  of  which  meets 
the  lower  end  of  the  handle  of  the  malleus  at  an 
obtuse  angle  which  opens  forwards.  This  blight 
spot  is  due  to  the  reflection  of  light.  Its  presence 
may  usually  be  accepted  as  a  proof  of  a  healthy  state 
of  the  membrane.  Immediately  above  the  short 
process  of  the  malleus  a  notch  may  be  observed  in 


Inflation.  471 

the  ring  of  bone  wliich  bounds  the  tympanic  mem- 
brane. The  part  of  the  membrane  which  fills  in  this 
notch  is  called  the  membrana  flaccida,  or  Shrapnell's 
membrane.  It  would  be  beyond  the  scope  of  this 
work  to  enter  into  a  description  of  the  various 
abnormal  appearances  which  may  be  met  with  in  the 
tympanic  membrane.  For  the  purpose  of  describing 
the  situation  of  any  abnormality  which  may  be  ob- 
served, it  is  customary  to  divide  the  membrane  into 
an  anterior  part,  which  is  in  front  of  the  handle  of  the 
malleus,  and  a  posterior  part,  which  lies  behind  it. 
Each  of  these  is  then  divided  by  an  imaginar}^  line 
drawn  through  the  tip  of  the  handle  into  a  superior 
and  an  inferior  portion.  Four  quadrants  are  thus 
obtained,  and  in  making  notes  one  should  say  that  a 
perforation  {e.g. )  is  seen  in  the  anterior  superior  quad- 
rant, and  so  on. 

Inflation  of  the  middle  ear. — It  is  some- 
times desirable  to  injlate  the  middle  ear  with  air. 
This  is  best  effected  by  aid  of  a  Politzer's  bag.  The 
bag  should  have  a  piece  of  rubber  tubing,  about  one 
inch  and  a  half  in  length,  attached  to  its  nozzle. 
Give  the  patient  a  mouthful  of  water,  and  tell  him 
to  keep  it  in  his  mouth  until  he  is  told  to  swallow  it. 
Introduce  the  rubber  tubing  into  the  lower  part  of 
one  nostril,  pinch  firmly  the  other  nostril  and  the 
upper  part  of  the  one  into  which  the  tubing  has  been 
introduced,  and,  holding  the  bag  in  the  palm  of  the 
right  hand,  tell  the  patient  to  swallow.  The  moment 
you  observe  the  larynx  rising  squeeze  the  bag  firmly, 
and  the  air  will  enter  the  middle  ear. 

To  ensure  the  entry  of  the  air  into  the  ear,  or  to 
direct  it  into  one  ear  only,  the  passage  of  the 
Enstaehian  catheter  may  be  necessary.  Hold 
the  instrument  lightly  near  the  broad  end  with  the 
thumb  and  two  finorers  of  the  right  hand.  With 
the  thumb  of  the  other  hand  push  the  point  of  the 


472  Examination  of  Throat. 

patient's  nose  gently  upwards.  Pass  the  end  of 
the  catheter  into  the  nostril  with  the  curve  of  the 
instrument  looking  downwards,  and  the  handle 
somewhat  lower  than  the  point.  Pass  it  backwai'ds 
along  the  floor  of  the  inferior  meatus,  and  as  soon  as 
the  curved  part  has  entered  the  nostril  raise  the 
handle  of  the  instrument  until  it  is  level,  and  con- 
tinue to  push  it  Imck  wards  until  it  comes  in  contact 
with  the  posterior  wall  of  the  pharynx.  Then  rotate 
the  instrument  till  its  point  is  directed  towards 
the  middle  line,  and  withdraw  it  until  the  curve 
hooks  against  the  posterior  end  of  the  nasal  septum. 
Then  rotate  the  instrument,  so  that  the  point  sweeps 
downwards  and  then  upwards  and  outwards,  the 
handle  being  kept  pressed  towards  the  nasal  septum, 
and  stop  when  the  ring  of  the  instrument  is  directed 
towards  the  outer  canthus  of  the  eye  of  the  same 
side.  The  point  of  the  instrument  can  then  usually 
be  felt  to  be  arrested  by  the  cartilaginous  rim  of 
the  tube.  The  nozzle  of  a  Politzer's  bag  may  then 
be  introduced  into  the  outer  end  of  the  instrument, 
and  the  inflation  accomplished. 

If  one  end  of  a  rubber  tube,  with  an  ear-piece 
at  each  extremity,  be  inserted  into  the  ear  of  the 
patient,  and  the  other  end  into  that  of  the  observer, 
the  latter  can  hear  the  sound  which  the  air  makes  as  it 
impinges  against  the  membrane.  If  a  whistling  sound 
be  heard,  it  indicates  the  existence  of  a  dry  perfora- 
tion.    A  bubbling  sound  shows  the  presence  of  fluid. 

SECTION  III.— THE   THROAT. 

The  methods  of  examining  the  fauces  and  the 
pharynx  have  already  been  considered  (p.  45).  In  order 
to  obtain  a  view  of  the  larynx,  one  must  have  recourse 
to  laryngoscopy.  In  performing  laryngoscopy, 
the  patient  and  observer  should  be  seated  opposite 
to  one  another  in  a  darkened  room,  and  about  a  foot 


Lar  yngoscop  y.  473 

apart.  A  light  should  be  placed  a  little  to  the  right 
(or  left)  of  the  patient's  head  and  on  a  level  with  his 
mouth.  An  ordinary  lamp  will  serve,  but  it  is  better 
to  have  an  Argand  burner,  and  it  is  also  an  advantage 
to  have  the  light  fitted  with  a  bull's-eye  condenser. 
The  observer  adjusts  the  reflector  to  his  head  by 
means  of  a  forehead  band  or  spectacle  frame.  If 
the  former  be  used,  the  two  knobs  on  the  band  should 
go  against  the  root  of  the  nose.  It  is  then  rotated 
on  its  ball  and  socket  joint  until  the  hole  in  the  centre 
is  directly  opposite  the  right  eye.  This  is  ascertained 
by  closing  the  left  eye  and  observing  whether  one  has 
a  clear  view  through  the  aperture.  One  can  also 
arrange  the  reflector  so  that  it  is  in  the  centre  of  the 
forehead,  and  one  then  looks  under  its  lower  edge. 
This  requires  a  little  practice,  but  his  the  advantage 
of  allowino"  one  to  make  use  of  both  eves.  It  is  also 
of  advantage  in  the  former  method  to  have  the 
aperture  in  the  centre  of  the  reflector  in  the  form  of 
an  elonfjated  slit  rather  than  of  a  round  hole,  as  a 
better  view  is  thus  obtained. 

The  observer  should  next  manipulate  the  reflector 
with  both  hands  until  the  lio;ht  is  directed  on  to  the 
patient's  mouth.  He  then  selects  a  mirror,  and 
warms  it  face  downwards  over  the  lamp  until  the 
moisture,  which  at  first  condenses  on  the  surface,  has 
all  dried  oS*.  He  should  also  touch  his  cheek  with 
the  back  of  the  mirror  before  inserting  it,  in  order  to 
make  sure  that  it  is  not  too  hot.  Having  warmed 
the  mirror,  he  should  hold  it  in  such  a  way  that  it  can 
be  readily  introduced  and  manipulated.  On  the  whole 
it  is  more  convenient  to  hold  the  mirror  like  a  pen  than 
in  any  other  way.  It  should  also  be  held  rather  short, 
so  that  the  hand  of  the  observer  can  be  steadied  by 
resting  the  little  finger  on  the  patient's  cheek. 

The  mirror  being  ready,  the  patient  is  told  to 
crane  out  his  neck  a  little,  and  to  open  his  mouth  and 


474  Examination  of  Throat. 

put  out  his  tongue.  The  observer  then  throws  a 
clean  dry  cloth  over  the  anteiior  part  of  the  latter, 
and  grasps  it  firmly  but  gently  between  the  forefinger 
and  thumb  of  the  left  hand.  It  must  be  held  firmly, 
but  without  any  squeezing,  and  should  then  be,  as  it 
"were,  rolled  out,  as  if  round  an  imaginary  axis 
situated  near  the  hyoid.  This  manoeuvre  has  the 
advantage  of  causing  a  better  elevation  of  the  epi- 
glottis, whilst  it  prevents  any  risk  of  injuring  the 
tongue  against  the  lower  incisor  teeth.  Before  intro- 
ducing  the  mirror  make  sure  that  the  light  from  the 
reflector  is  concentrated  on  the  back  of  the  patient's 
throat.  This  having  been  ascertained,  the  mirror 
should  next  be  introduced  with  its  surface  turned 
almost  directly  downwards,  and  passed  rapidly  back, 
care  being  taken  to  avoid  touching  either  the  tongue 
or  the  palate.  The  patient  should  be  told  to  be  sure 
to  breathe  regularly  and  through  his  nose.  This 
serves  to  engross  his  attention.  As  the  soft  palate 
rises  during  an  inspiration,  the  back  of  the  mirror  is 
placed  gently  against  it,  opposite  the  base  of  the  uvula. 
The  soft  palate  is  then  gently  pushed  upwards  and 
backwards,  and  the  handle  of  the  instrument  lowered 
or  raised  until  the  back  of  the  epiglottis  comes  into 
view.  The  patient  is  then  told  to  say  "  Eh,"  and 
that  usually  causes  the  vocal  cords  to  become  visible. 

If  the  reflex  excitability  of  the  patient's  pharynx 
be  very  great,  so  that  any  attempt  to  introduce  the 
mirror  induces  retching,  the  application  of  a  10  per 
cent,  solution  of  cocaine  previous  to  beginning  the 
examination  will  be  found  of  great  assistance. 

It  must  be  remembered  also  that  one  sometimes 
meets  with  a  patient  whose  larynx  baffles  all  attempts 
at  inspection  owing  to  the  position  and  shape  of  the 
epiglottis. 

In  studying  the  vieu^  obtained,  the  true  cords 
usually  first  attract  attention  owing  to  their  gleaming 


Lar  yngoscop  v. 


,  ,  Fig,  129.— Diagram  of  larynx. 

right  and  left,  respirat  on  ;  6   recuVrent     ef^  nh^^^^^  =  5.  abductor 

respiration  :  8,  recurrent    rteht    nVwi    i^-fi      '  P^i^iiation  ;  7,  recurrent,  left, 
arytenoid,  pWnS  •  ?o   amenoM  anfi  t'hv^^^^^  phonation  ;   9 

Phonation  ;  11,  thyro-aVvteno?ds  St  ifr.Vi'iJT";?,'"^''^^  P§^^t  and  left 

in  the  mirr'or/le.ytie'ii\-I'leffhao^o°?sifve\^\Tgh^     ^'^  ^'^'^''^^  ««^° 


476  Examination  of  Throat. 

white  colour.  They  should  move  freely  on  phona- 
tion.  Tracing  them  forwards,  they  are  seen  to  con- 
verge and  disappear  behind  the  cushion  of  the 
epiglottis.  Posteriorly  they  diverge  and  terminate 
in  knob-like  prominences,  which  are  the  apices  of 
the  arytenoid  cartilages.  Immediately  internal  to 
each  of  these  is  a  smaller  knob — the  cartilage  of 
Wrisberg.  Passing  backwards  from  each  side  of  the 
epiglottis  to  the  arytenoid  cartilages  are  seen  the 
ary-epiglottic  folds.  In  favourable  circumstances  the 
observer  can  see  down  the  trachea,  and  even  as  far 
as  its  bifurcation.  This  is  facilitated  by  the  observer 
placing  himself  at  a  lower  level  than  the  patient,  and 
holding  the  mirror  in  such  a  way  that  its  surface 
looks  almost  directly  downwards. 

In  observing  any  abnormal  condition  of  the 
larynx,  the  chief  points  to  be  attended  to  are — - 

(1 )  The  colour  of  the  cords  and  mucous  membrane; 

(2)  The  presence  of  any  swelling  or  ulceration ; 

(3)  The  mobility  of  the  vocal  cords. 

1.  The  normal  colour  of  the  vocal  cords  is  a  pearly 
white.  In  laryngitis  they  become  red.  Any  increase 
or  diminution  in  the  redness  of  the  laryngeal  mucous 
membrane  should  be  noted.  In  tubercular  affections 
the  mucous  membrane  is  abnormally  pale ;  in  syphi- 
litic conditions  it  is  unusually  red. 

2.  The  position  and  character  of  the  swelling 
should  be  noted.  Tumefaction  of  tlie  aryepiglottic 
folds  and  of  the  epiglottis  should  be  looked  for  in  sus- 
pected laryngeal  phthisis.  Tumours  of  various  sorts 
on  the  true  cords  are  occasionally  met  with.  As  re- 
gards ulcers,  note  their  number,  their  position,  and 
the  character  of  their  floor.  Tubercular  ulcers  are 
usually  multiple,  and  are  met  with  very  frequently  on 
the  interarytenoid  fold.  Syphilitic  ulcers  are  usually 
single,  and  have  a  yellow  sloughy  floor. 

3.  Observe   whether   the    cords    come    together 


Rhixoscopv.  477 

normally  on  phonation  and  ujien  widely  duiing  in- 
spiration. In  adductor  pai'aly!i»i!!»  the  affected 
cord  fails  to  move  inwards  on  phonation,  or  the  cord 
makes  a  sudden  Diovement  inwards  and  then  goes 
back,  the  position  being  unsustained  (Fig.  129 — 2,  3). 
In  abductor  paralysis  the  cord  looks  normal 
on  phonation,  but  fails  to  move  outwards  again  on 
inspiration  (Fig.  129 — 4,  5). 

In  paralysis  of  both  abductors  and  adductors 
(paralysis  of  the  whole  recurrent  laryngeal  nerve,  or 
"  recurrent  paralysis  ")  the  cord  is  fixed  in  the 
cadaveric  position — i.e.  midway  between  complete 
adduction  and  abduction.  This  is  much  more  common 
on  the  left  than  on  the  right  side,  owing  to  the  greater 
liability  of  the  left  recurrent  laryngeal  nerve  to  be 
pressed  upon  by  aneurysms  (Fig.  129 — G,  7,  8). 

Adductor  paralysis  is  usually  the  result  of  func- 
tional disease.  Abductor  paralysis,  on  the  other  hand, 
is  the  forQi  of  paralysis  characteristic  of  an  organic 
lesion  of  the  nervous  systera.  Bilateral  adductor 
paralysis  or  paresis  is  the  cause  of  the  condition 
known  as  hysterical  aphonia. 

If  on  phonation  the  cords  come  together  incom- 
pletely, leaving  an  elliptical  space  between  them, 
there  is  paralysis  of  the  internal  thyro- 
arytenoids present  (Fig.  129 — ll).  If  the  anterior 
two-thirds  of  the  cords  come  together,  but  leave  a 
triangular  cleft  beliind,  the  interarytenoid  muscle 
is  affected  (Fig.  129 — 9).  For  further  details  regarding 
these  forms  ofparalysis  special  works  must  be  consulted. 

SECTION   lA^.— THE   NOSE. 

Anterior  rhinoscopy. — The  position  of  the 
patient  and  of  the  observer,  and  the  arrangement  of 
the  light  aud  reflector,  are  the  same  as  for  laryngoscopy. 

The  anterior  nares  should  first  be  inspected  with- 
out the  aid  of  a  speculum.     Tilt  the  tip  of  the  nose 


478  Examination  of  Nose. 

upwards  with  the  finger,  and  note  the  presence  of  any 
eczematous  or  ulcerated  condition  of  the  mucous 
membrane  or  skin.  Observe  whether  any  dried 
secretion  or  blood  can  be  seen.  Look  for  any  swell- 
ing, ulceration,  or  perforation  of  the  cartilaginous  part 
of  the  septum. 

Having  noted  tliese  points,  take  a  solid  two-bladed 
speculum,  warm,  and  introduce  it.  Hold  it  in  position 
with  the  left  hand,  and  gently  screw  the  blades  apart 
with  the  right.  The  first  object  to  be  observed  is 
usually  the  anterior  end  of  the  inferior  turbinated 
body.  Note  whether  it  is  larger  than  normal  or  not. 
If  it  be  enlarged,  touch  it  with  a  probe  so  as  to  ascer- 
tain whether  the  enlargement  be  osseous  or  due  to 
swelling  of  the  mucous  membrane  merely.  Then  de- 
press the  patient's  chin  somewhat  so  as  to  bring  the 
inferior  meatus  into  view ;  then  ask  him  to  hold  his 
head  a  little  back  so  as  to  obtain  a  view  of  the  middle 
meatus  and  middle  turbinated  body.  The  latter  is 
considerably  lighter  in  colour  than  the  inferior  turbin- 
ated. The  superior  meatus  can  never  be  seen,  and 
the  superior  turbinated  only  very  rarely. 

The  presence  of  polypi  should  be  specially  looked 
for  in  these  parts.  Their  recognition  is  facilitated  by 
the  use  of  the  probe.  Lastly,  turn  the  patient's  head 
a  little,  so  that  the  septum  can  be  inspected.  Note  any 
deviation  of  it,  or  the  presence  of  any  prominence  or 
spine  or  the  existence  of  any  ulceration  or  perforation. 

Swelling  of  the  inferior  turbinated  body  sometimes 
obstructs  the  view  of  the  rest  of  the  nasal  cavity.  The 
application  of  a  little  10  percent,  cocaine  on  a  pledget 
of  wool  will  usually  cause  the  swelling  to  disappear. 

Posterior  rhinoscopy.  —  This  is  tlie  only 
method  of  obtaining  a  view  of  the  posterior  nares.  In 
carrying  it  out,  the  position  of  the  observer,  the 
patient,  the  reflector_,  and  the  light  should  be  the  same 
as  for  laryngoscopy.      The  patient,  however,  should 


Rhinoscopy. 


479 


have  the   chin   rather  depressed,  the  neck  not  being 

craned  out  as  in  the  examination  of  the  hirynx. 

Select  the  smallest  laryngeal  mirror,  warm  it,  and 
ask  the  patient  to  open  his  mouth.  It  is  sometimes 
an  advantage  to  have  the  shaft  of  the  mirror  bent 
back  a  little  about  1^  in.  above  the  reflecting  surface. 
Introduce  a  right-angled  tongue  depressor,  and  hold 


Fig.  130. — Posterior  nares  and  surrounding  parts. 

1,  Beptuni :  2,  middle  turbinated  hone ;  3,  inferior  turbinated  bone ;  4,  superior 
turbinated  hone;  5,  superior  meatus;  6,  middle  meatus;  ;,  inferior  meatus; 
8.  main  passage  of  nostrils  ;  9.  vault  of  pharynx;  10,  cushion  of  soft  palate  ; 
11,  posterior  surface  of  uyula ;  12,  ridge  formed  by  levator  palati ;  13,  sal- 
pin  go- pharyngeal  fold;  14,  salpingo-palatine  fold;  15,  Eustachian  cushion  ; 
16;  fossa  of  Rosenmuller  ;  ir,  Eustachian  orifice. 

down  the  tongue  witlj  the  left  hand.  Take  the  mirror 
in  the  right  hand,  and  pass  it  in  with  the  surface 
looking  upwards.  Introduce  it  behind  the  soft  palate, 
passing  along  between  the  uvula  and  the  left  anterior 
pillar  of  the  fauces  Then  turn  the  mirror  a  little, 
so  that  its  surface  looks  upwards  and  forwards.  The 
posterior  nares  will  then  come  into  view,  What  one 
usually  sees  first  is  the  posterior  end  of  the  nasal 
septum.  It  looks  narrow,  sharp,  and  pale  in  colour 
below,  but  expands  a  little  and  looks  reddish  above  ; 
a  slight  cushion-like  swellinij  can  also  be  often  seen 
about  the  middle  of  it  on  each  side  (Fig.  130). 

On  the  outer  wall  the  posterior  end  of  the  middle 


480  Examination  of  Nose. 

tiirl)inated  bone  can  usually  be  easily  seen  as  a  large 
bluisli-red  swelling.  Above  it,  one  can  st^e  the  supeiior 
meatus  and  the  end  of  the  superior  turbinated  bone ; 
below  it  is  the  middle  meatus  and  the  upper  part  of 
the  inferior  turbinate.  Observe  the  presence  of  any 
increase  in  size  of  any  of  these  objects.  Note  also  the 
general  character  and  colour  of  the  mucous  membrane, 
or  whether  any  mucus  or  pus  can  be  seen  adhering  to 
it.  Next  turn  the  mirror  a  little  upwards  and  to  one 
side,  keeping  it  rather  low  down,  and  with  its  back 
against  the  tonsil,  and  look  for  the  cushion  of  the 
opposite  Eustachian  tube,  which  can  usually  be  made 
out.  It  forms  a  bright  red  rounded  projection,  bound- 
ing a  depression  Avhicli  leads  to  the  orifice  of  the 
Eustachian  tube.  Observe  whether  there  is  any 
secretion  at  the  mouth  of  the  latter,  or  any  adenoid 
swelling  of  the  mucous  membrane. 

Lastly  turn  the  surface  of  the  mirror  upwards,  and 
examine  the  vault  of  the  naso-pharynx,  noting  espe- 
cially the  presence  of  any  adenoid  swelling  oi-  tumour 
in  that  region.  Normally  the  roof  should  present  an 
appearance  not  unlike  that  of  the  surface  of  the  tonsil 
(Luschka's,  or  the  pharyngeal  tonsil). 

Posterior  rhinoscopy  is  often  very  difficult  to  per- 
form. Tire  difficulty  may  be  due  to  there  being  very 
little  room  between  the  posterior  wall  of  the  pharynx 
and  the  soft  palate.  If  this  cannot  be  overcome  by 
inducing  the  patient  to  breathe  quietly  through  the 
nose,  or  to  sniff,  it  may  be  necessary  to  introduce  a 
palate  retractor,  but  for  a  description  of  this  process 
special  works  must  be  consulted.  Even  after  the 
mirror  is  pi'operly  introduced,  it  is  not  always  easy 
to  recognise  what  one  sees.  This  is  largely  due  to 
the  fact  that  only  a  small  portion  is  seen  at  one  time, 
and  the  mirror  has  to  be  turned  about  till  every  part 
has  been  viewed  separately.  Experience  can  alone 
overcome  these  difficulties. 


CHAPTER    XL 

LocoMOTORY    System. 

(Bones^  Joints,   Gait.) 

The  locomotory  system  includes  the  muscles,  bones, 
and  joints.  The  examination  of  the  Diuscles  is  most 
conveniently  considered  along  with  that  of  the  nervous 
system  (Chap.  IX. ).  There  remain  for  consideration 
the  bones  and  joints. 

£xaiuiiiatioii  of  the  bones. — In  the  case  of 
the  long  bones  of  the  limbs,  look  (Ij  at  the  condition  of 
the  shaft,  (2)  at  the  articular  ends. 

As  regards  the  shaft,  note  any  distension  or  bend- 
ing of  the  bone  and  any  signs  of  a  former  fracture. 
Tlien  pass  the  hand  along  the  bone,  noting  the  presence 
of  any  tenderness  or  thickening  of  it.  Thickening  is 
most  likely  to  be  detected  on  the  exposed  surfaces  of 
bones,  e.g.  over  the  anterior  surface  of  the  tibia  and  at 
the  lower  ends  of  the  radius  and  ulna.  Such  thicken- 
ing often  affords  valuable  evidence  of  old  periostitis, 
especially  of  the  syphilitic  form. 

As  regards  the  ends  of  the  hones,  note  the  pres- 
ence of  any  general  enlargement,  such  as  occurs  in 
rickets,  or  of  any  nodulation  at  the  margins,  such  as  one 
finds  in  rheumatoid  arthritis. 

In  examining  a  joint,  note  first  the  points  which  can 
be  m'ade  out  by  simple  inspection.  Observe  the  posi- 
tion in  which  the  patient  keeps  the  joint ;  note  any 
alterations  in  its  contour,  such  as  local  or  general  swell- 
ing, and  the  presence  or  absence  of  any  redness.  Then 
pass  to  palpation,  noting  whether  or  not  there  is  any 
increase  of  local  heat  in  the  joint,  whether  it  is  tender 
to    the   touch,   and    whether    one  can  make  out   the 

P  F 


482  Loco  MO  TORY  System. 

presence  of  any  fluctuation  in  the  joint  cavity.  Then 
tiy  to  move  the  joint,  observing  the  degree  of  mobility 
in  each  direction,  and  whether  or  not  attempts  at 
movement  produce  pain.  If  the  joint  is  movable, 
note  whether  any  sensation  of  grating  is  produced  on 
movement.  If  the  mobility  is  limited  in  one  or  every 
direction,  try  to  form  a  conclusion  as  to  the  cause  of 
the  limitation,  and  especially  whether  it  is  due  to 
changes  in  the  components  of  the  joint  itself,  e.g.  con- 
traction of  ligaments,  or  fibrous  or  bony  anchylosis,  or 
whether  it  is  due  to  changes  in  the  structures  sur- 
rounding the  joint,  e.g.  shortening  of  tendons.  Next 
turn  your  attention  to  the  synovial  membrane.  Try 
to  make  out  whether  there  is  any  thickening  or  boggi- 
ness  of  it.  Lastly  examine  the  articular  surfaces  of 
the  bones,  moving  the  joint  (if  possible)  so  that  the 
edges  of  the  articular  surfaces  can  be  examined  with 
the  fingers.  Note  the  existence  of  any  irregularity  or 
thickening  of  these,  and  the  presence  of  any  outgrowth 
or  "  lipping  "  of  them. 

The  vertebral  eoluniii  and  iskiill  demand 
special  attention.  Observe  in  the  former  the  presence 
of  any  local  projection  of  the  vertebral  spines.  If 
such  there  be,  state  which  are  the  vertebrse  involved, 
and  at  which  the  projection  is  most  prominent.  In 
counting  the  vertebrae  for  this  or  any  other  purpose, 
one  can  take  as  landmarks  either  the  spine  of  the 
vertebra  prominens  or  the  last  rib,  tracing  the  latter 
back  to  the  twelfth  dorsal  vertebra. 

In  many  cases,  liowever,  the  last  rib  cannot  be 
distinctly  felt.  It  is  therefore  rather  untrustworthy 
as  a  guide. 

Note  also  the  presence  of  any  curvature  of  the 
spinal  column  as  a  whole,  or  of  one  part  of  it,  distin- 
guishing carefully  such  general  curvature  from  the 
local  projections  above  referred  to. 

The  curvature  may  be  in  an  anterior  or  a  posterior 


Vertebral  Column.  483 

direction,  or  laterally.  Anterior  curvature  is  termed 
lordosis,  and  is  commonest  in  the  lumbar  region. 
General  posterior  curvature  is  spoken  of  as  kyj^hosis. 
It  occurs  most  typically  in  the  dorsal  region  in  old 
persons,  and  must  be  distinguished  from  the  localised 
angular  curvature  of  spinal  caries.  Lateral  curvature 
is  termed  scoliosis,  and  may  be  towards  either  the 
right  or  the  left  side.  It  is  always  accompanied  by  a 
rotation  of  the  bodies  of  the  vertebrae  in  such  a  way 
that  the  spines  come  to  point  towards  the  concavity 
of  the  curve.  An  absence  of  the  normal  curves 
of  the  spine  may  be  an  indication  of  commencing 
vertebral  disease. 

Ask  the  patient  to  stoop  down,  and  notice  the 
degree  of  mobility  of  the  vertebral  column,  and  the 
occurrence  of  any  pain  during  stooping,  noting  the 
exact  site  of  the  latter,  if  present.  Then  pass  the 
hand  down  the  vertebral  column,  and  observe  whether 
any  tender  spots  can  be  made  out.  Such  tender 
spots  are  not  infrequently  met  with  in  hysteria  and 
in  cases  of  irritation  of  the  posterior  nerve  roots. 
Their  presence  can  often  be  more  easily  elicited  by 
drawing  a  sponge  wrung  out  of  hot  water  down 
the  vertebral  column ;  the  patient  complains  of  pain 
whenever  the  hyper  aesthetic  area  is  reached.  To 
elicit  more  deep-seated  tenderness  of  the  vertebrae,  it 
may  be  necessary  to  "punch  "  the  spines  gently  with 
the  fist  from  above  downwards,  observing  the  point 
at  which  the  patient  complains  of  pain  and  verifying 
the  observation  by  repeating  the  process  from  below 
upwards. 

In  studpng  the  skull,  note  first  its  size.  For 
this  purpose  it  may  be  necessary  to  take  lueasiire- 
nients.  This  should  be  done  in  three  directions : 
(1)  Antero-posteriorly  from  the  root  of  the  nose  to 
the  external  occipital  protuberance;  (2)  circumfer- 
entially    at    the  level    of    a    line  drawn  horizontally 


484  Loco  MO  TORY  System. 

round  tlie  skull  from  the  supra-orbital  ridges  in  front 
to  the  external  occipital  protul^erance  behind ;  (3) 
coronally  from  one  auditory  meatus  to  the  other.  If 
the  skull  is  abnormally  small,  the  patient  is  micro- 
cephalic. This  is  frequent  in  some  forms  of  idiocy. 
Abnormal  enlargements  of  the  skull  occur  in  hydro- 
cephalus, in  ostitis  deformans,  and  in  acromegaly. 

JSText  observ^e  the  sliape  of  the  skull.  Is  it 
of  the  dolichocephalic  (long-headed),  or  the  brachy- 
cephalic  (bullet-headed)  type  ]  Are  the  two  sides  of 
the  head  symmetrical  ?  Certain  well-recognised  types 
of  abnormal  skull  are  met  with.  In  hydrocephalus, 
the  skull  tends  to  assume  a  globular  form.  The  fore- 
head is  overhanging  and  the  eyes  are  pushed  down  so 
that  the  upper  part  of  the  sclerotic  is  exposed.  The 
lateral  aspects  of  the  skull  (above  the  ears)  project 
outwards.  If  the  patient  is  a  child,  as  is  usually  the 
case,  the  fontanelle  is  wide  and  bulging,  and  often 
fluctuates  very  distinctly.  The  sutures  may  be  opened 
up,  and  imperfectly  ossified  areas  (craniotabes)  may 
be  detected  in  the  bones.  In  7'ickets  the  skull  tends 
to  be  square  or  oblong  and  box-shaped.  The  frontal 
and  parietal  bones  often  show  central  thickening 
("bossing").  The  forehead,  however,  does  not  over- 
hang, nor  are  the  eyes  depressed,  and  although  the 
fontanelle  is  usually  widely  open,  it  does  not  bulge 
as  it  does  in  hydrocephalus,  nor  are  the  sutures 
opened  up.  In  congenital  syphilis  the  forehead  is 
vertical,  the  frontal  eminences  are  often  exaggerated, 
and  the  bridge  of  the  nose  is  depressed. 

Having  noted  the  general  shape  of  the  skull, 
ask  the  patient  to  open  his  mouth,  so  that  one  may 
see  the  hard  palate.  Observe  its  width  and  degree 
of  arching.  A  high,  much-arched,  and  narrow  palate 
is  often  one  of  the  minor  signs  of  mental  deficiency. 

Next  proceed  to  the  palpation  of  the  skull. 
Note  first  the  thickness  of  the  scalp,  and  whether  it 


Palpation  of  Skull.  485 

moves  freely,  as  it  ought,  upon  the  subjacent  bone. 
Atrophy  and  adherence  of  the  scalp  are  apt  to  be 
associated  with  skin  diseases  in  this  region,  and  are 
often  a  bar  to  successful  treatment.  Observe  the 
presence  or  absence  of  inequalities  in  the  bones, 
such  as  may  indicate  the  site  of  former  injury  or 
fracture.  If  a  swelling  be  detected,  pay  special  at- 
tention to  its  margins,  noting  whether  a  hard  rim  can 
be  made  out,  and  whether  or  not  the  rim  disappears 
on  firm  pressure  steadily  applied  by  the  finger  for 
a  minute  or  two.  In  blood  extravasations  the  rim 
disappears,  in  a  depressed  fracture  it  persists.  I^ote 
also  whether  the  swelling  can  Ije  moved  as  a  wljole 
upon  the  skull  or  not.  If  the  patient  be  a  child,  note 
the  condition  of  the  fontanelles  and  sutures,  and  look 
for  the  presence  of  unossified  areas  in  the  bones 
(craniotabes).  The  best  place  to  look  for  these  is 
in  the  neighbourhood  of  the  lambdoidal  suture.  They 
feel  like  little  spots  which  are  covered  only  by  parch- 
ment. Observe  the  presence  of  any  tender  spots  or 
areas  on  the  skull.  For  this  purpose  it  may  be  neces- 
sary to  tap  the  skull  gently  all  over  with  tlie  fore- 
finger. If  tenderness  is  detected,  note  carefully  its 
maximum  point.  Such  tender  points  are  sometimes 
met  with  in  inflammatory  affections  of  the  cranial 
bones  or  membranes,  and  in  cases  of  superficially 
situated  intracranial  tumours,  but  they  may  also 
be  present  in  neuralgic  affections  of  the  scalp. 

The  Gait. 

The  character  of  a  patient's  gait  is  often  an 
important  indication  of  the  nature  of  the  affection 
from  which  he  is  suffering.  It  is  specially  important 
in  cases  of  nervous  disease. 

In  studying  the  gait,  it  is  well,  if  possible,  to 
have  the  legs  fully  exposed.  For  this  purpose  the 
patient  should  have  on  only  a  night-shii-t  or  dressing- 


486  Loco  MO  TORY  System. 

gown,  which  should  be  brought  through  between 
the  legs  from  behind,  and  pinned  up  in  front.  The 
feet  should  be  bare.  The  patient  is  then  told  to 
walk  away  from  the  observer,  to  turn  round  at  a 
given  point,  and  then  to  come  towards  him  again. 

If  it  be  desirable  to  obtain  a  permanent  record  of 
the  patient's  footprints,  one  can  have  recourse  to 
photography.  Put  on  the  feet  a  pair  of  woollen 
socks,  and  dip  them  in  rather  thick  whiting.  Then 
ask  the  patient  to  walk  along  a  smooth  floor.  The 
marks  left  by  the  feet  can  then  be  photographed. 

In  studying  the  gait,  the  points  to  toe  noted 
are  : — [  1 )  Can  the  patient  walk  at  all  ?  This  being 
decided,  one  has  to  ask  on  self — (2)  Does  he  pursue  a 
straight  line,  or  does  he  tend  to  deviate  to  one  side  or 
the  other,  or  to  both  alternately?  To  bring  out  this 
point,  it  is  well  to  ask  the  patient  to  walk  along 
a  straight  line — e.g.  a  crack  in  the  floor.  (3)  Does  he 
tend  to  fall,  and,  if  so,  in  what  direction?  These 
questions  being  settled,  the  next  point  to  be  decided 
is  whether  the  gait  conforms  to  any  of  the  Avell- 
recognised  abnormal  types.  Before  one  tries  to  make 
up  one's  mind  in  this  matter,  however,  it  is  well  to 
be  quite  sure  that  the  peculiarity  in  the  patient's  gait 
is  not  due  to  some  surgical  cause  or  to  local  disease  of 
a  joint — e.g.  rheumatoid  arthritis  of  the  hip.  For 
example,  we  have  known  the  peculiar  gait  which  is 
affected  by  patients  with  congenital  double  dislocation 
of  the  hip  to  be  mistaken  for  the  result  of  weakness 
of  the  muscles  of  the  back,  and  treated  by  massage 
and  electricity.  A  previous  examination  of  the  bones 
and  joints  will  eliminate  such  sources  of  fallacy. 

The  three  chief  types  of  abnormal  gait  due  to 
nervous  affections  are  : — 

1.  The  spastic  ; 

2.  The  ataxic  ; 

3.  The  reeling. 


The  Gait.  487 

In  taking  a  patient's  case,  it  is  usually  sufficient  to 
state  that  the  gait  belongs  to  one  or  other  of  these 
types,  or  is  a  combination  of  one  or  more  of  them. 
The  chief  peculiarities  of  each  variety  are  as  follows  : — 

1.  The  spastic  may  be  described  as  a"  sticky  "  gait. 
The  patient  has  difficulty  in  bending  his  knees,  and 
drags  his  feet  along  as  if  they  were  glued  to  the 
floor,  the  toes  scraping  the  ground  at  each  step.  The 
foot  is  raised  from  the  ground  by  tilting  the  pelvis, 
and  the  leg  is  then  swung  forwards,  so  that  the  foot 
tends  to  describe  an  arc. 

This  gait  is  seen  most  characteristically  in 
patients  with  lateral  sclerosis  of  the  cord.  The 
lieiiiiple^ic  g°ait  is  a  unilateral  form  of  the  spastic 
type. 

2.  The  ataxic  maybe  described  as  a  "s^am;;m^" 
gait.  The  patient  raises  his  feet  very  suddenly  often 
abnormally  high,  and  then  jerks  them  forward, 
bringing  them  to  the  ground  again  with  a  stamp, 
and  often  heel  first.  He  seems  to  exhibit,  also,  an 
indefiniteness  of  purpose  in  the  place  chosen  to  put 
down  the  foot,  and  the  feet  while  in  the  air  do  not 
move  in  one  plane,  but  are  waved  about,  as  it  were, 
before  being  set  down.  By  adopting  a  "  broad  base," 
the  patient  tries  to  counteract  the  unsteadying  effects 
of  his  style  of  progression.  This  gait  is  best  seen  in 
cases  of  locomotor  ataxy. 

3.  The  reeliBig"  gait  may  be  described  as  a 
"  drunken  "  gait,  and,  therefore,  requires  no  further 
description.  It  will  be  observed  that  patients  with 
this  gait  walk  "on  a  broad  base,"  the  feet  being 
planted  widely  apart.  It  is  important  to  notice 
whether  supporting  the  patient  by  his  axillse  abolishes 
the  reeling  tendency.  In  some  cases  of  cerebellar 
disease,  such  support  has  been  observed  to  abolish 
the  patient's  vertigo  for  the  time  during  which  he 
is  supported. 


488  LOCOMOTORY    SySTEI\T. 

This  gait  occurs  most  typically  in  cases  of  cere- 
bellar lesion.  It  is,  therefore,  sometimes  referred  to 
as  a  "cerebellar  gait." 

Some  rarer  varieties  of  abnormal  gait  may  be 
briefly  referred  to.     These  are  :  — 

The  "festinaiit  gait."  This  is  the  form  of  gait 
met  with  in  typical  cases  of  paralysis  agitans.  The 
patient  is  bent  forwards,  and  advances  with  rapid 
short  shuffling  steps,  so  that,  as  has  been  said,  "he 
looks  as  if  he  were  trying  to  catch  his  centie  of 
gravity."  In  some  cases,  if  one  suddenly  pulls  the 
patient  backwards,  he  begins  to  walk  backwards, 
and  is  unable  to  stop  himself,  though  he  is  leaning 
forwards  all  the  time.  This  peculiar  phenomenon  is 
spoken  of  as  "  retrojndsion.^^ 

The  waddling-  or  oscillating  gait  is  like  the  gait 
of  a  duck.  The  body  is  usually  tilted  backwards, 
there  being  a  degree  of  lordosis  present;  the  feet  are 
planted  rather  widely  apart;  and  the  body  sways  more 
or  less  from  side  to  side  as  each  step  is  taken.  The 
heels  and  the  toes  tend  to  be  brought  down  simul- 
taneously. The  chief  peculiarities  of  this  gait  are  due 
to  a  difficulty  in  maintaining  the  centre  of  gravity  of 
the  body  owing  to  weakness  of  the  muscles  of  the  back. 
It  is  met  with  in  pseudohypertrophic  paralysis. 

The  tiig-li-stepping:  or  prancing  gait  is  a  device 
adopted  by  the  patient  to  prevent  his  tripping  from 
his  toes  catching  the  ground.  It  is,  therefore,  met 
with  in  cases  where  the  toes  tend  to  droop  from  weak- 
ness of  the  extensor  muscles,  e.g.  in  peri)")heral  neuritis 
affecting  the  anterior  tibial  nerve.  The  name  suf- 
ficiently describes  its  characters. 


489 


CHAPTER  XII. 

The  Clinical  Examination  of  Children. 

The  clinical  examination  of  young  children  is  a 
matter  full  of  difficulty  to  the  inexperienced.  It  has 
to  be  carried  out,  not  merely  without  the  hel})  of  the 
patient,  but  often  in  spite  of  his  strenuous  opposition. 
In  this  cliapter  we  propose  to  point  out  the  best 
methods  of  ascertaining  the  necessary  facts,  and  also 
the  chief  points  in  which  the  child  differs  from  the 
adult  in  a  clinical  sense. 

The  history  of  the  patient  and  his  illness  must,  of 
course,  in  the  case  of  young  children,  be  ascertained 
from  the  mother  or  friends.  The  best  §c;lieBiie  of 
iuterrog^ation  to  employ  will  be  found  on  p.  10. 
Whilst  the  history  is  being  elicited  opportunity  may  be 
taken  to  cultivate  the  friendship  of  the  child  or,  at  all 
events,  to  get  him  accustomed  to  one's  presence.  The 
history  having  been  ascertained,  one  proceeds  to  an 
examination  of  the  child.  This  requires  gentleness 
and  deliberation,  combined  with  infinite  patience  and 
good  temper.  If  one  is  at  all  hurried  or  rough,  the 
child  begins  to  cry  at  once,  and  the  subsequent 
examination  is  rendered  a  thousandfold  more  difficult. 
We  would  emphasise  the  fact  that  it  is  almost  im- 
possible to  be  really  systematic  in  one's  examination 
of  children.  Certain  things  must  always  be  looked 
for,  but  no  definite  order  can  be  observed  in  looking  for 
them.  One  has  to  seize  the  opportunity  of  ascertain- 
ing a  fact  as  it  presents  itself^  and  a  rigorous  adherence 
to  "  systems  "  is  often  out  of  the  question.  In  the  first 
place,  a  number  of  points  can  be  ascertained  before  the 
child  is  undressed.     One  can  study  the  lacies  of  the 


49 o  Examination  of  Children. 

child,  note  its  complexion,  the  colour  of  its  lips,  and 
whether  or  not  the  alee  nasi  are  acting.  One  should  also 
at  this  period  of  the  examination  count  the  respiration 
and  pulse-rate  ;  it  is  very  important  to  get  these  noted 
while  the  child  is  still  undisturbed. 

The  respirations  can  usually  be  counted  by 
merely  watching  the  movements  of  the  child's  abdomen, 
that  being  very  much  more  affected  by  respiration 
in  young  children  than  the  chest  is.  The  normal 
rate  of  a  newly-born  child  is  40  or  so  respirations 
per  minute,  by  the  second  year  they  have  fallen  to  30 
or  so,  at  the  fifth  year  they  are  about  25,  and  by  fifteen 
they  have  sunk  to  20.  Much  more  important  than 
the  absolute  number  of  respirations  is  the  ratio 
of  respiration  to  pulse.  Normallv  this  should  be  as 
l:3ior4. 

The  pulse  is  best  counted  by  allowing  the  mother 
to  hold  the  child's  hand  in  hers ;  the  fingers  of  the 
physician  are  then  quietly  slipped  over  the  mother's 
hand  on  to  the  child's  wrist  and  the  pulse  counted. 
If  the  child  has  begun  to  cry,  it  is  useless  to  take  the 
pulse-rate,  as  it  may  be  at  least  20  beats  above  the 
normal  rate.  The  pulse-rate  at  birth  should  be  130, 
by  the  second  year  it  has  reached  110,  by  the  fifth  100, 
by  the  eighth  90,  and  by  the  twelfth  80  ;  after  this  it 
gradually  sinks  to  the  normal  adult  rate.  During 
sleep  the  pulse-rate  always  falls  about  10-20  beats. 
As  a  matter  of  fact,  the  examination  of  the  pulse  in 
infancy  is  of  comparatively  little  clinical  value.  It  is  of 
little  use  as  an  index  of  the  vital  powers,  the  fonta- 
nelle  replacing  it  in  that  respect.  The  vessel  being 
extremely  small,  the  characters  of  the  pulse-wave  can 
hardly  be  ascertained  ;  irregularity  by  itself  is  of  com- 
paratively little  significance,  being  very  common,  even 
in  healthy  infants,  and  being  almost  the  rule  in  sleep. 
A  pulse  which  is  continuously  slow  and  irregular  is, 
however,  of  great  significance, 


General  Examination.  491 

These  pveliminary  facts  having  Ijeeii  noted,  the 
child  should  be  stripped  and  })laced  in  a  blanket  on 
the  knee  of  the  mother  or  nurse  ;  examination  must 
then  be  proceeded  with  by  the  usual  methods  of  in- 
spection, j^alpation,  auscultation,  and  percussion.  In 
the  clinical  investigation  of  children  it  must  be  noted 
that  the  two  former  methods  are  of  much  the  greatest 
assistance. 

It  is  well  to  begin  l)y  looking  and  feeling  the  child 
all  over.  One  notes  the  general  state  of  develop- 
ment and  nutrition,  the  state  of  the  skin,  whether 
dry  and  fevered,  or  moist,  and  the  presence  or  absence 
of  any  rash  or  skin  eruptions,  and  whether  or  not  the 
normal  degree  of  elasticity  is  present.  The  shape  of 
the  chest  and  the  degree  of  prominence  of  the  abdomen 
should  be  noted,  it  being  borne  in  mind  that  the  rickety 
and  pigeon-breasted  types  of  chest  are  very  common 
in  diseased  children,  and  that  a  rather  protuberant 
abdomen  is  to  be  regarded  as  normal.  The  hand 
should  then .  be  lightly  passed  over  the  head.  The 
state  of  the  anterior  foiitaiieSle  should  first  be 
investigated.  The  fontanelle  closes  normally  between 
the  fifteenth  month  and  the  second  year.  If  it  re- 
mains patent  after  the  secoiid  year,  it  is  often  a  sign 
of  disease  —  most  usually  of  rickets.  Too  early 
closure  of  the  fontanelle  occurs  in  some  forms  of 
microcephaly  and  idiocy. 

The  degree  of  tension  of  the  fontanelle  is  of  great 
importance.  In  health  it  pulsates  distinctly,  and 
is  neither  sunken  nor  unduly  elevated.  A  depressed 
fontanelle  is  an  important  sign  of  exhaustion;  a  tense 
fontanelle  indicates  increased  intracranial  pressure. 
It  must  be  borne  in  mind,  of  course,  that  the  fontanelle 
is  normally  tense  when  the  child  is  crying.  The 
systolic  bruit  heard  over  the  fontanelle  is  of  no 
clinical  importance. 

The    shape  of  the  head    and    of    its     bones 


492  Examination  of  Children 

must  be  investigated.     The  development  of  **  bosses  " 

("  Parrot's  nodes  ")  on  the  frontal  and  parietal  bones 
is  a  common  occurrence  in  rickets,  especially  in 
syphilitic  children.  One  should  also  look  for  evidence 
of  craniotabes  (in  young  babes)  and  of  rheumatic 
nodules  (in  older  children).  The  general  shape  of 
the  head  as  a  whole  should  always  be  noted  ;  it  may 
be  box-shaped  as  in  rickets,  globular  in  hydro- 
cephalus ;  it  may  be  abnormally  small  or  large,  or 
it  may  be  asymmetrical. 

Passing  from  the  head,  one  may  examine  the  long" 
bones.  In  children,  this  is  of  extreme  impoi-lance; 
many  of  the  commonest  and  most  serious  diseases  of 
infancy  affect  the  bones  more  prominently  than  any 
other  part  of  the  body.  Look  for  thickening  or  ten- 
derness along  the  shafts  of  the  bones.  This  may  be 
due  to  scurvy,  to  syphilitic  or  to  suppurative  j)eriostitis, 
or  to  tumours.  Examine  carefully  the  epiphyses. 
In  rickets  these  become  enlarged.  This  is  most  easily 
seen  where  the  ribs  join  their  cartilages,  the  thick- 
ening there  forming  a  row  of  bead-like  prominences 
("rickety  rosary").  It  is  also  easily  seen  at  the 
wrists.  The  frequency  of  inflammatory  affections  of 
the  epiphyses  should  also  be  borne  in  mind.  The 
presence  or  absence  of  ''rheiiBJiatic  nodules" 
should  also  be  noted.  These  are  little  fibrous  bodies 
varying  in  size  from  that  of  a  lai  ge  pin's  head  to  a 
pea,  or  even  bigger.  They  occur  not  in  the  periosteum, 
but  in  the  deep  fascia,  where  it  covers  superficial 
bones,  and  also  in  the  sheaths  of  tendons.  They 
should  be  looked  for  especially  over  the  olecranon  and 
patella.  They  are  usually  movable,  but  not  tender. 
If  found,  they  are  pathognomonic  of  rheumatism. 
The  vertebral  column  should  always  be  examined 
for  siorns  of  tubercular  disease  or  curvature. 

At  this   point,   if  not   earlier,    the    child's    tem- 
perature should  be  taken.     In  young  children  the 


Palpation^  Auscultation^  Percussion.    493 

thermometer  should  be  inserted  into  the  rectum,  or 
l)hiced  in  tlie  groin  or  axilla  ;  in  older  children  it  may 
be  placed  in  the  mouth.  It  should  be  remembered  that 
the  temperature  in  children  is  much  more  variable 
than  in  adults,  and  often  goes  up  upon  very  little 
provocation. 

One  must  now  proceed  to  the  examination  of 
the  thorax  and  abdomen*  The  front  of  the 
chest  and  the  abdomen  may  be  examined  together, 
and  either  after  or  before  the  posterior  aspect  of  the 
chest.  The  order  adopted  should  be,  firstly,  inspection 
and  palpation,  then  auscultation,  and,  last  of  all,  per- 
cussion. Percussion  is  left  to  the  last,  owing  to  the 
fact  that  it  frequently  makes  the  child  cry. 

In  palpation,  be  sure  that  the  hand  is  Cjuite 
warm;  this  is  even  more  important  in  examining  the 
child  than  in  the  case  of  an  adult.  In  auscultation 
one  should  use  either  the  immediate  method — the  ear 
being  applied  to  the  skin  directly  (this  is  only  applic- 
able in  examining  the  back),  or  else  one  should  use  a 
binaural  stethoscope.  The  latter  enables  one  to 
follow  slight  movements  on  the  part  of  tlie  child 
better  than  one  can  with  a  wooden  instrument.  If 
the  chest-piece  of  the  stethoscope  is  made  of  metal, 
remember  to  warm  it  before  applying  it  to  the  chest. 
There  is  only  one  point  to  be  observed  in  the  per- 
cussion of  a  child,  and  that  is,  that  the  stroke 
should  be  light.  This  is  not  merely  in  order  to  avoid 
frightening  the  little  patient,  but  also  to  escape  the 
confusion  which  is  apt  to  arise  from  the  excessive 
resonance  of  the  child's  chest. 

When  the  abdomen  and  front  of  the  chest  have 
been  run  over  in  this  way,  one  should  turn  his  atten- 
tion to  the  posterior  aspect  of  the  lungs.  For  the 
examination  of  these,  the  child  should  not  be  laid  on 
his  face,  as  that  interferes  with  respiration,  and  causes 
the   abdominal  viscera   to    push    up   the   diaphragm, 


494  Examination  of  Children. 

but  lie  should  be  held  against  the  mother's  breast 
with  bis  head  looking  over  her  shoulder.  In  this  way 
the  wliole  of  the  back  of  the  chest  can  be  gone  over. 

Last,  but  by  no  means  least,  comes  the  examination 
of  the  nioiitli  and  throat.  It  is  impossible  to 
exaggerate  the  importance  of  systematically  examin- 
ing the  mouth  and  throat  in  all  cases  of  illness  in 
children.  At  the  same  time,  it  is  just  this  pai't  of  the 
clinical  examination  in  which  we  are  most  likely  to 
meet  with  opposition;  and  for  that  reason  it  is  let't  to 
the  last,  as  it  may  be  necessary  to  employ  coercion  in 
order  to  get  it  carried  out. 

Begin  by  looking  at  the  tongue.  Sometimes  the 
child  will  put  out  its  tongue  when  asked.  In  little 
babies  gentle  pressure  on  the  chin  will  often  cause 
the  mouth  to  be  opened,  when  a  view  of  the  tongue 
can  be  obtained.  Or  if  a  drop  of  milk  or  a  little 
sugar  be  placed  just  outside  the  lip,  the  child  will 
often  put  out  its  tongue  in  order  to  lick  it  off.  In 
more  refractory  children  it  may  be  necessary  to  push 
the  lower  lip  over  the  teeth,  and  then  to  press  the  lip 
down  against  the  lower  incisors.  The  child  then 
opens  its  mouth  in  order  to  avoid  having  its  lip  cut. 
With  very  obstinate  children  one  may  be  obliged  to 
compress  the  nostrils  until  the  mouth  is  opened  to 
get  breath. 

Once  the  child  has  been  induced,  either  voluntarily 
or  by  aid  of  one  of  the  above  devices,  to  open  its 
mouth,  one  should  note  the  state  of  the  buccal 
mucous  membrane,  remembering  the  frequency 
of  thrush,  stomatitis,  and  ulcerations  in  children. 
The  number  and  character  of  the  teeth  should  be 
observed  (see  also  p.  42),  and  the  finger  should  be 
run  along  the  gum  to  feel  for  any  teeth  that  may 
be  about  to  come  through.  One  must  then  proceed 
to  an  examination  of  the  throat.  The  child  should 
be  wrapped  in  a  towel  to  restrain  the  movements  of 


Throat.  495 

its  arms.  The  mother  or  nurse  sits  down  opposite  a 
good  light  and  takes  the  child  on  her  lap.  Another 
assistant  steadies  the  child's  head  from  behind.  The 
child  having  then  been  induced  or  compelled  to  open 
its  mouth,  one  introduces  a  small-sized  tongue  de- 
pressor and  holds  down  the  tongue,  thus  exposing 
the  pharynx.  The  linger  will  often  serve  instead  of 
an  instrument,  and  has  the  advantage  of  friofhteninsf 
the  child  less.  Look  for  any  enlargement  of  the 
tonsils,  for  any  redness  of  the  mucous  membrane, 
and  especially  for  the  presence  of  any  membranous 
patches  on  it. 

Palpation  of  the  pharynx  must  also  be  carried 
out  in  many  cases.  To  do  this  one  must  stand  behind 
the  child,  and  when  its  mouth  is  open  push  in  the 
cheek  from  one  side  between  its  molar  teeth.  This 
serves  as  a  gag,  and  effectually  prevents  the  child 
from  attempting  to  bite.  The  forefinger  is  then 
passed  to  the  back  of  the  pharynx  and  up  behind  the 
soft  palate.  Note  the  presence  of  any  adenoids,  or 
any  bulging  into  the  posterior  wall  of  the  pharynx, 
which  may  be  an  indication  of  the  presence  of  a 
retro  pharyngeal  abscess. 

AVe  have  now  indicated  the  general  routine  method 
to  be  employed  in  examining  a  child,  but  there 
remain  some  special  points  which  we  have  not  yet 
taken  up.  These  we  shall  consider  briefly  under 
the  difTerent  systems  : — 

1.  General  condition. — Special  importance  at- 
taches to  the  regular  weighing  of  children.  Altera- 
tions in  weight  from  time  to  time  are  of  much  help 
in  prognosis  and  treatment.  It  should  be  remem- 
bered that  a  healthy  child  should  weigh  at  birth 
about  7  lbs.  This  should  be  doubled  by  the  time 
the  fifth  month  is  reached,  and  trebled  in  the  first 
year.  By  the  sixth  year  it  is  again  doubled,  so  that 
a   healthy    child    of    six    should    weigh    about   three 


496 


Examination  of  Children. 


stones.     This  is  again  doubled  when  the  fourteenth 
year  is  reached. 

Measiireiueiit  of  the  head  is  often  of  irnportance 


Pirr  131  —Position  of  viscera  in  child  of  five.     (Ajter  Symington,  "  Topo- 
°'  graphical  Anatomy  of  the  ChiUl,"  Phate  XII.) 

Two  measurements  are  usually  sufficient — a  coronal 
measurement  from  one  auditory  meatus  to  the  other, 
and  a  circumferential  measurement  at  the  level  of  the 
root  of  the  nose  and  external  occipital  protuberance.* 

*  The  circumference  of  the  head  at  nine  months  should  be 
about  17  in.  ;  at  twelve  months,  about  19  in.  ;  at  seven  years, 
20-21  in.  After  three  years  of  age  a  circumferential  measurement 
of  19  in.  is  too  small. 


Alimentary  and  Circulatory  Systems.     497 

2.  Aliiiieiitary  system. — Note  that  the  liver 
is  normally  rather  large  in  children,  and  usually 
reaches  at  least  half  an  inch  below  the  costal  margin. 
Enlargement  of  the  spleen  is  very  frequent  in 
infantile  diseases.  It  is  best  made  out  by  palpa- 
tion, the  hand  being  passed  across  the  child's 
abdomen  from  right  to  left.  By  depressing  the 
finger  tips  opposite  the  eleventh  interspace  the  edge 
of  the  spleen,  if  the  organ  is  enlarged,  may  be  felt 
as  it  descends  during  inspiration. 

Inspection  of  the  stools  should  never  be  omitted. 
The  healthy  infant,  on  the  breast  or  bottle  only,  has 
two  or  three  stools  daily.  These  should  be  of  the 
colour  and  consistence  of  beaten-up  eggs.  Any 
alterations  in  frequency,  colour  or  consistence,  or  the 
presence  of  worms,  should  be  carefully  noted. 

3.  Circulatory  systean. — Note  that  the  apex 
beat  of  the  child  is  normally  rather  higher  than  in 
the  adult.  It  is  usually  in  the  fourth  space  just  out- 
side the  mammary  line  (Fig.  131).  It  should  also  be 
observed  that  alterations  in  the  general  contour  of 
the  preecordia  are  much  more  frequent  results  of 
cardiac  disease  in  children  than  in  adults.  As 
regards  aiisciiltation,  it  should  be  remembered 
that  the  pulmonary  second  sound  in  the  young  child 
is  normally  rather  louder  than  the  aortic.  The  pul- 
monary second  is  accentuated  if  it  be  permanently 
louder  than  the  first.  The  aortic  second  is  accen- 
tuated if  it  be  as  loud  as  the  pulmonary. 

Remember  also  that  hsemic  bruits  are  very  rare 
in  babies,  while  congenital  bruits  are  relatively  very 
frequent.  We  have  already  mentioned  that  the 
cardiac  rhythm  in  the  child  is  not  infrequently 
irregular  even  in  health. 

4.  The  blood. — It  is  sometimes  difficult  to  ^et 
a  large  enough  drop  of  blood  from  the  ear  of  a  child. 
In  that  case,  a   piece  of  woollen  thread  shoald  be 

G  G 


498  Examination  of  Children. 

twisted  round  the  thumb — not  too  tightly — and  the 
latter  punctured  with  a  triangular  needle  at  the  root 
of  the  nail.  In  very  young  children  nucleated  red 
blood  corpuscles  are  normally  present  in  the  blood 
in  small  numbers.  The  leucocytes  are  more  numerous 
in  the  child  than  in  the  adult;  12,000  per  cnim.  is 
not  uncommon.  The  uni-nucleated  leucocytes  are 
relatively  more  abundant  than  in  the  adult.  In 
newly-born  babies  the  percentage  of  haemoglobin  is 
often  very  high. 

5.  Kespiratory  system, — A  child  uses  its 
diaphragm  much  more  than  its  intercostals  in 
breathing.  Hence  the  movements  are  chiefly 
abdominal,  and  there  is  little  real  chest  expansion. 
Any  indrawing  of  the  lower  interspaces  on  inspira- 
tion should  always  be  looked  for.  It  occurs  wherever 
there  is  obstruction  to  the  entrance  of  air  {e.g.  diph- 
theria), but  may  also  be  present  where  there  is 
collapse  of  the  lower  parts  of  the  lungs,  and  also  in 
pneumonia.  In  "  extra-auscultation  "  one  should  be 
on  the  outlook  for  any  stridor,  and  for  the  existence 
of  a  short,  grunting  expiration.  The  latter  is  a 
frequent  sign  of  severe  respiratory  disease.  In  the 
adult  the  normal  cycle  of  respiration  is,  of  course, 
inspiration,  expiration,  pause.  In  the  child  this  is 
often  reversed,  so  that  one  gets  first  a  short 
expiration,  succeeded  by  a  longer  inspiration,  and 
then  by  a  pause.  This  reversal  is  specially  frequent 
in  respiratory  disease  or  embarrassment.  The  re- 
spiratory pauses  are  often  very  prolonged  in  the 
child,  so  that  one  has  to  wait  a  long  time  if  one  is 
auscultating  before  the  next  inspiration  is  heard. 
The  normal  breath  sound  in  the  child  is,  after  the 
age  of  six  months  or  so,  puerile  in  type.  Vocal 
resonance  is  often  difficult  to  estimate.  In  babies 
one  may  make  use  of  the  cry  as  a  producer  of  vocal 
resonance ;    in    older   children    one   may    ask    them 


Respiratory  and   Urinary  Systems.      499 

their  name,  get  them  to  count,  etc.  It  should  be 
remembered  as  a  general  rule  that  if  the  breath 
sounds  are  distinctly  harsher  on  one  side  than  the 
other,  then  the  harsh  side  is  probably  the  normal. 
Children's  chests  conduct  sound  very  readily.  Hence 
abnormal  sounds,  especially  crepitations,  are  very  apt 
to  be  heard  on  both  sides,  although  they  are  really 
only  being  produced  on  one.  The  great  frequency 
of  collapse  of  part  of  the  lung  should  be  borne  in 
mind  in  diagnosing  pulmonary  disease  in  infancy. 
In  percussing  the  lungs  in  children  one  must,  as 
already  mentioned,  use  a  very  light  stroke.  One 
should  also  take  care  only  to  percuss  when  the  chest 
has  been  filled  by  an  inspiration,  otherwise  one  may 
be  led  into  thinking  that  there  is  dulness  present. 

It  should  also  be  remembered  that  the  chest-wall 
of  a  young  child  is  so  elastic  that  one  can  often  obtain 
the  "cracked-pot"  sound  on  heavy  percussion,  even 
although  the  lung  be  perfectly  healthy.  This  is 
especially  apt  to  happen  if  the  child  is  crying. 

6.  Urinary  system. — It  is  difficult  to  collect  the 
total  quantity  of  urine  passed  by  a  child  per  diem. 
A  rough  table  of  the  average  quantity  for  each  age 
will  be  found  at  p.  268.  It  will  be  observed  that  the 
totals  are  surprisingly  low.  The  specific  gravity,  on 
the  other  hand,  is  relatively  higher  than  in  adults. 
Sugar  is  very  rarely  present  in  the  urine  of  children. 

7.  IVei'voiis  system. — Motor  paralysis  is  to 
be  made  out  by  watching  whether  the  child  ever 
moves  the  suspected  limb.  One  cannot  estimate  the 
paralysis  as  one  does  in  adults  by  means  of  passive 
resistance.  Remember  that  inability  to  walk  is  not 
necessarily  a  sign  of  paralysis  of  the  legs.  One 
must  note  whether  the  legs  are  moved  when  the 
child  is  sitting  or  lying.  Thus  a  rickety  child  may 
not  be  able  to  walk,  but  moves  his  leg  freely  if  one 
tickles  the  soles.     A  child   with  infantile  paralysis 


5QO  Examination  of  Children. 

of  the  legs  cannot  move  the  limbs  in  any  circum" 
stances. 

The  knee  jerks  in  little  children  are  best 
elicited  by  placing  the  child's  foot  on  one's  hand  as  a 
stirrup,  and  then  gently  percussing  the  tendon.  The 
latter  lies  rather  to  the  outer  side  in  the  child,  and  is 
comparatively  narrow,  so  that  one  may  easily  miss  it. 

The  superficial  reflexes  are  usually  more  brisk 
in  healthy  children  than  in  adults.  Tlie  exact  local- 
isation of  sensory  paralysis  is  extremely  difficult 
in  children,  but  sensory  lesions  occur  but  rarely  in 
infancy. 

In  examining  the  eyes  with  the  ophthalmoscope, 
the  direct  method  is  that  which  it  is  best  to  employ. 
The  child  may  be  examined  while  lying  on  its  back, 
a  lamp  being  held  alongside  the  head,  but  at  a  some- 
what lower  level.  It  may  be  necessary  to  hold  open 
the  lids,  but  as  far  as  possible  avoid  touching  the 
child  at  all.  One  must  often  be  satisfied  with  mere 
fleeting  glimpses  of  the  disc. 

In  testing  light  perception  in  little  children,  it  is 
best  to  hold  a  candle  in  front  of  the  eyes,  and  see  if 
they  attempt  to  follow  its  movements.  One  may  also 
threaten  the  cornea  by  suddenly  bringing  the  finger 
near  it,  and  observing  whether  the  child  winks  before 
the  eye  is  touched. 

In  examining  the  ears,  one  must  remember  the 
shortness  of  the  auditory  meatus  in  the  child,  and  the 
great  obliquity  of  the  drum  membrane.  The  magni- 
fication of  the  view  by  means  of  an  ophthalmoscopic 
lens  is  a  useful  aid  in  these  cases. 

It  is  often  difficult  to  gauge  the  intellectual 
capacity  of  a  young  child.  Early  signs  of  idiocy 
are — inability  to  support  the  head,  which  often  rolls 
about  helplessly  ;  causeless  screaming ;  inability  to 
notice  things  ;  and  backwardness  in  grasping. 

In  older  children  we  can  inquire  as  to  progress  at 


Intellectual  Capacity, 


501 


school,  etc.,  or  ask  the  patient  questions.  Get  him 
to  count,  multiply,  and  so  on.  The  position  of  the 
child  in  the  school  is  a  rough  guide  to  the  develop- 
ment of  the  intelligence.  A  normal  child  remains  in 
the  infant  school  until  he  is  seven  years  of  age,  after 
which  he  enters  the  standards.  The  averao^e  aije  of 
the  children  in  each  standard  is  as  follows  : — 


Standard 

I. 

7-8  years 

II. 

8-  9      „ 

III. 

9-10      „ 

lY. 

...       10-11      „ 

Y. 

...       11-12      „ 

YI. 

...       12-13      „ 

YII. 

...        13-14      „ 

A  normal  child  should  have  begun  to  walk  a  little 
by  the  age  of  eighteen  months.  Talking  begins  at  a 
variable  time  after  this.  The  distinction  drawn  by 
West  between  children  that  are  idiotic  and  those 
that  are  merely  backward  may  also  be  of  help  in 
the  investigation  ;  a  backward  child  would  be  normal 
for  a  younger  age  ;  an  idiot  would  be  abnormal  at 
any  age. 


502 


CHAPTER   XIII. 

The  Examination  op  Pathological  Fluids. 

In  this  chapter  we  pi^opose  to  deal  witli  the  method 
of  examining  fluids,  which  may  be  obtained  from  one 
of  the  body  cavities  or  from  abnormal  growths,  in 
order  to  obtain  information  which  may  be  of  help  in 
diagnosis. 

The  flnid  is  obtained  by  means  of  "  exploratloii." 
An  ordinary  hypodermic  needle  may  be  employed, 
but  special  "exploring"  needles — which  are  really 
merely  large  and  strong  hypodermics — are  also  sold. 
The  needle  should  be  of  such  calibre  that  it  is  capable 
of  sucking  up  oil.  If  it  is  able  to  do  that,  it  will  be 
able  to  suck  up  any  fluid  likely  to  be  met  with  in 
exploring.  Before  being  used,  the  needle  should  be 
sterilised.  This  is  best  done  by  slipping  it  into  a 
test  tube,  covering  it  with  water  or  weak  carbonate 
of  soda  solution,  and  boiling  for  three  minutes.  It 
should  then  be  placed  in  boracic  lotion.  The  use  of 
strong  carbolic  lotion  for  sterilising  exploring  needles 
is  to  be  avoided,  as  it  produces  a  coagulation  of  albu- 
minous fluids,  which  may  block  the  needle  or  cause 
the  fluid  to  seem  opalescent.  The  patient's  skin 
should  be  cleansed  with  some  1  in  20  carbolic  acid  at 
the  spot  selected  for  puncture.  As  a  rule,  it  is  not 
necessary  to  employ  any  local  anaesthetic.  In  very 
nervous  patients  a  small  spot  of  skin  may  be  frozen 
by  means  of  the  ethyl  chloride  spray.  It  should  be 
remembered,  however,  that  the  local  reaction  after 
freezing  causes  really  more  pain  than  the  original 
puncture.  The  needle  should  be  held  short,  with  the 
forefinger    of    the    operator   resting    on   it   near   the 


Where  to  Puncture.  503 

point.  It  should  be  introduced  rapidly  and  steadily, 
but  without  any  "  stab."  When  the  needle  has  been 
fully  entered,  the  piston  is  withdrawn.  Should  no 
fluid  be  obtained,  the  needle  is  drawn  slowly  out- 
wards, whilst  a  negative  pressure  is  maintained  in  the 
syringe.  It  may  then  be  found  that  fluid  is  obtained 
nearer  the  surface. 

Where  to  Puncture. 

In  the  case  of  the  pleural  cavity,  the  puncture 
is  best  made  in  the  9th  or  10th  space  midway 
between  the  posterior  axillary  and  scapular  lines, 
this  being  the  point  at  which  fluid  which  is  lying  free 
in  the  cavity  is  most  likely  to  be  obtained.  In  cases  of 
localised  dulness,  one  must  be  guided,  of  course,  by 
circumstances.  Usually,  however,  one  selects  that 
point  where  the  dulness  is  most  absolute  and  the 
breath  sound  faintest. 

Puncture  of  the  peritoneal  cavity  may  be  per- 
formed either  in  the  middle  line  through  the  linea 
alba,  or  laterally,  about  a  point  on  a  line  with,  but 
rather  above,  the  anterior  superior  spine.  The  former 
position  ensures  that  no  large  blood-vessel  will  be 
injured ;  but  by  lateral  puncture  one  is  more  certain 
of  entering  fluid,  especially  if  the  patient  be  turned 
over  somewhat  on  to  the  side  of  operation.  Before 
puncturing  in  the  middle  line  be  sure  the  bladder  is 
empty,  and  never  insert  a  needle  at  any  point  unless 
it  yields  a  dull  note  on  moderately  heavy  percussion. 

In  puncturing  the  peri  car  diiiiii  one  should 
select  a  spot  in  the  third,  fourth  or  fifth  interspace, 
at  a  distance  of  ^  in.  to  1  in.  from  the  left  margin  of  the 
sternum,  the  exact  spot  dej)ending  on  the  degree  of 
distension  of  the  sac. 

Litimbar  puncture  is  a  method  now  not  in- 
frequently resorted  to  for  ascertaining  the  character 
of  the  effusion  in  cases  of  increased  exudation  into 


504  Pathological   Fluids. 

the  subdural  space.  It  is  most  usually  required  in 
children.  Au  antitoxin  needle  is  best  for  the  pur- 
pose. The  patient,  preferably  anaesthetised,  should 
be  on  his  right  side,  slightly  bent  forward,  and  lying 
over  so  that  the  spine  is  towards  the  operator.  Trace 
the  last  rib  back  to  the  twelfth  dorsal  spine,  and 
count  down  from  this  to  the  third  lumbar.  Put  the 
left  thumb  on  the  third  interspinous  space,  enter  the 
needle  \  in.  to  the  right  of  it,  and  pass  slightly  in- 
wards and  upwards  for  a  depth  of  |  in.  to  1  in.,  depend- 
ing on  the  age  of  the  patient.  A  syringe  is  not 
essential,  but  forms  a  useful  handle  to  the  needle. 
The  fluid  usually  escapes  in  drops ;  a  continuous  flow 
indicates  increased  pressure.  Lateral  movement  of 
the  needle  should  be  avoided,  as  it  may  produce 
bleeding.  The  fluid  should  be  collected  in  a  sterilised 
test  tube.  Its  characters  and  their  significance  will 
be  referred  to  later. 

In  the  exploration  of  cysts,  etc.,  one  must  be 
guided  by  local  circumstances,  the  rule  being  to 
select  for  puncture  that  parb  of  the  tumour  which 
is  nearest  the  surface,  and  where  one  is  not  likely 
to  injure  important  structures. 

Examination  op  the  Fluid. 

The  fluid  having  been  obtained,  it  should  ])e 
transferred  to  a  conical  glass  and  allowed  to  settle. 

Note  first  its  physical  cliaracters.  The  chief 
of  these  are  the  colour,  consistence,  specific  gravity, 
odour,  and  the  appearance  of  the  deposit  (if  any). 

As  regards  the  colour  of  tlie  fluid,  one  of  the  most 
important  points  to  note  is  whether  it  is  bloodstained 
or  not.  It  must  be  borne  in  mind,  however,  that  a 
small  amount  of  blood  is  apt  to  get  into  the  fluid 
in  the  process  of  exploring.  Observe,  also,  whether 
the  fluid  is  transparent,  opaque,  or  opalescent. 

Opacity  is  usually  due  to  the  presence  of  cellular 


Chemical  Investigation.  505 

elements ;  opalescence  to  fatty  particles  or  large 
numbers  of  micro-organisms. 

Pathological  fluids  are  usually  of  a  more  or  less 
watery  consistence.  Viscidity  usually  indicates 
the  presence  of  mucin.  It  should  be  carefully  noted 
whether  or  not  the  consistence  of  the  fluid  alters  on 
standing.  Many  pathological  fluids  clot  after  standing 
for  some  time.     The  clot  consists  of  tibrin. 

The  specific  gravity  is  taken  with  a  urinometer, 
the  same  precautions  being  used  as  in  the  case  of  urine 
(p.  274). 

Most  fluids  are  devoid  of  odour;  sometimes, 
however,  they  are  extremely  fetid. 

The  amount  and  colour  of  the  deposit  should  be 
noted.  If  red,  it  probably  consists  of  red  blood 
corpuscles  ;  if  white,  it  may  be  made  up  of  leucocytes, 
cancer  cells,  etc. 

For  clieMiical  investigation  the  fluid  should 
first  be  filtered.  In  the  examination  of  the  filtrate 
the  following  points  must  be  attended  to  : — 

(1)  The  reaction.  This  is  almost  invariably  alka- 
line.     Sometimes  it  is  neutral. 

(2)  The  presence  of  sernm  albumin  and  serum 
globulin.  This  is  ascertained  by  means  of  the  same 
tests  as  have  already  been  described  for  the  urine 
(p.  297).  If  these  proteids  are  present  in  large  amount, 
the  fluid  is  coagulated  on  boiling,  even  although  the 
reaction  is  alkaline.  If  proteids  are  scanty,  the  fluid 
sliould  be  first  rendered  slightly  acid  by  means  of 
dilute  acetic  acid. 

As  in  the  case  of  the  urine,  nothing  is  gained  by 
testing  for  albumin  and  globulin  separately.  Albii- 
moses  and  peptone  are  almost  never  found  in 
the  fluids  under  consideration. 

The  quantitative  estimation  of  albumin  and 
globulin  cannot  be  accurately  carried  out  in  ordinary 
clinical  work.     Approximate  results  may  be  obtained 


5o6 


Pa  t ho  logic  a  l   Fl  uids. 


by  tlie  use  of  Esbach's  tulje.  The  fluid  must  first  be 
7ery  freely  diluted,  so  as  to  bring  the  specific  gravity 
down  to  1,008,  and  should  then  be  rendered  acid  by 
means  of  acetic  acid  (see  p.  300). 

(3)  The  presence  of  imiciii  or  iiiicleo-albiiniin 


Fig,  132.— Foulis'  cells. 


is  proved  by  the  appearance  of  a  precipitate  on  the 
addition  of  acetic  acid.     The  method  of  distinguishing 
betvi^een  the  two  has  been  already'  indicated  (p.  303). 
(4)  Siig-ar  should  be  tested  for  by  rendering  the 


MiCR  OS  CO  PIC  A  L   EXA  MINA  TION. 


507 


Fig.  133.— Cliolesterin  crystals. 


fluid  slightly  acid,  boiling,  and  filtering.  The  filtrate 
is  then  evaporated  down  to  a  small  bulk,  and  the  tests 
for  glucose  described 
at  pp.  308-13  applied. 
(5)  Urea  is  not 
often  present,  except 
in  traces,  in  ordinary 
pathological  fluids.  In 
fluids  derived  from 
the  urinary  organs  it 
may  be  more  abun- 
dant, and  should  be 
tested  for  by  removing 
all  proteids  by  heat, 
evaporating  the  fil- 
trate to  a  small  bulk, 
and  then  testing  for  urea  as  described  on  p.   286. 

Microscopic  Examination  of  the  Sediment. 

Some  of  the  deposit 
is  taken  up  with  a 
pipette,  and  a  drop  of 
it  placed  on  a  slide, 
covered,  and  examined. 
If  desired,  films  of  it 
may  be  made  in  the 
same  way  as  in  the  case 
of  blood  (p.  197).  This 
succeeds  fairly  well  if 
the  deposit  consists  of 
cancer  cells. 

One  may  recognise 
under  the  microscope 
(1)  elements  derived 
from  the  blood — al- 
tered red  and  white 
corpuscles. 


The  recog- 


Fig.     134.— Fatty    needles    and 
crystals  in  degenerated  cells. 


fatty 


5o8 


Pathological  Fluids. 


nition  of  altered  white  corpuscles  or  pus  cells  is 
facilitated  by  mixing  with  a  dro])  of  the  deposit 
a  small  quantity  of  a  1  per  cent,  solution  of 
acetic  acid  to  which  a  little  methyl  green  has 
been  added.  The  nuclei  are  then  more  easily  re- 
cognised.    (2)    Epithelial  cells    of   various   sorts. 

The  recognition  of  cancer 

j  -  -  cells  is  of  special  impor- 

f  n,        tance.     The   addition  of 

^  ;    '^rA       a  little   picrocarmine  or 


magenta  facilitates  the 
process.  .Do  not  mis- 
take ordinary  endothelial 
cells  for  them.  Cancer 
cells  should  be  large, 
numerous,  and  show 
grouping  here  and  there. 
The  cells  met  with  in 
fluids  derived  from  malig- 


^^^ 


W>  -'v:- •  '■  •  '^^^^^"^^^^ 


pus,  from  a  case  of  actinomycosis 
of  the  csecum.     x  300. 


nant    ovarian    cysts,    or 
malignant  peritonitis  f ol- 

Fig.  135.— Colony  of  actinomyces  in       lowing     SUch     Cysts,     are 

known  as  Foulis'  cells 
(Fig.  132).  They  are 
large  cells  containing  one  or  more  nuclei  about 
the  size  of  a  red  blood  corpuscle.  They  may  have 
either  a.  smooth  outline  or  may  show  little  buds  or  pro- 
jections indicating  rapid  proliferation.  (3)  In  fluids 
derived  from  hydatid  cysts  scolices  and  liooklels 
may  be  found  (p.  93).  (4)  Crystals— e.(/.  of  chole- 
sterin  (Fig.  133),  or  fatty  acids  (Fig.  134),  fragments 
of  muscular  tissue,  etc. — are  sometimes  met  with. 
(5)  The  pus  from  cases  of  actinomycosis  contains 
small  seedlike  nodules.  If  one  of  these  is  bruised 
between  a  slide  and  cover  glass,  and  examined  with 
the  high  power,  it  will  be  seen  to  consist  of  a  central 
mass   of   detritus,  radiating    out  from   which   are    a 


Inflammatory  Effusions.  509 

number  of  club-shaped  highly  refractile  bodies 
(Fig.  135).  If  there  is  any  ditticulty  in  identifying 
the  fungus,  cover-slip  preparations  should  be  made, 
and  stained  by  Gram's  method  (Appendix,  20).  For 
other  staining  methods,  see  p.  533.  (6)  The  detec- 
tion of  the  Aiiiopba  dyseuterise  in  the  pus  of 
abscesses,  especially  in  the  liver,  is  often  of  great 
diagmostic  value.  The  orcjanism  is  described  at 
p.  95.  If  one  fails  to  find  it  in  pus  removed  by 
exploration  or  in  that  obtained  when  the  abscess  is 
first  opened,  one  must  not  jump  to  the  conclusion 
that  it  is  not  present  in  the  abscess.  It  frequently 
does  not  appear  in  the  discharge  until  three  or  four 
days  after  the  abscess  has  been  opened.  This  is 
probably  to  be  explained  by  the  fact  that  the  habitat 
of  the  organism  is  in  the  wall  of  the  abscess 
(Manson). 

General  Characters  of  the  Principal  Fluids. 

1,  Inflaiiiuiatory  aud  dropsical  effusions. 

Inflammatory  effusions  are  often  spoken  of  as 
exudates ;  dropsical  effusions  as  transudates.  They 
present  the  same  general  appearances,  being  clear 
fluids  of  a  vellowish  ofreen  colour,  and  containing 
much  albumin  and  globulin.  It  is  very  difficult 
to  tell  a  dropsical  from  an  inflammatory  fluid  by 
chemical  or  other  examination.  It  would  appear 
that  the  amount  of  proteids  in  an  effusion  depends 
much  more  upon  site  than  upon  cause.  Pleural 
fluids  contain  the  highest  percentage  of  proteids, 
peritoneal  fluids  rather  less,  and  subcutaneous  fluids 
very  little.  The  fluid  in  cardiac  dropsy  is  more 
highly  albuminous  than  in  dropsy  of  renal  origin. 
From  a  diagnostic  point  of  view  all  one  can  say  is 
that  a  fluid  with  a  specific  gravity  of  more  than  1,018, 
which  contains  more  than  4  per  cent,  of  albumin, 
is  almost  certainly  inflammatory  ^  while  one  with  a 


5IO  Pathological  Fluids. 

specific  gravity  of  less  than  1,01-^),  and  an  albumin 
percentage  of  less  than  2|-,  is  certainly  dropsical. 
Between  these  limits  one  must  be  in  doubt.  Nor 
is  the  occurrence  of  coagulation  in  the  fluid  after 
tapping  of  much  help.  If  the  coagulation  be  very 
rapid  and  complete,  the  fluid  is  probably  inflam- 
matory, but  considerable  coagula  may  form  even  in 
purely  dropsical  fluids  after  standing  for  some 
time. 

Variations  in  the  specific  gravity,  etc.,  of  fluids 
obtained  by  repeated  tapping  in  the  same  case  are 
of  no  prognostic  value.  A  marked  rise  in  specific 
gravity  and  amount  of  albumin  may,  however, 
indicate  the  supervention  of  inflammation. 

2.  Fluid  obtained  by  lumbar  puncture.— 
Ordinar}'-  cerebro-spinal  fluid  is  perfectly  clear  and 
colourless,  resembling  distilled  water.  It  contains 
very  little  albumin  {^-^  per  cent.),  and  if  evaporated 
to  a  small  bulk  or  tested  will  be  found  to  reduce 
Fehling's  solution,  owing,  probably,  to  the  presence  of 
pyrocatecliin.  This  is  the  kind  of  fluid  which  is  found 
in  cases  of  cerebral  tumour.  In  cases  of  meningitis 
the  fluid  is  not  clear,  but  turbid  from  the  presence  of 
cellular  elements.  The  turbidity  may  be  so  slight 
that  it  is  only  noticed  after  shaking  the  fluid  and 
holding  it  up  to  the  light.  It  contains  quite  an 
appreciable  amount  of  albumin,  varying  from  \  per 
cent,  in  chronic  cases  up  to  1  or  2  per  cent,  in  those 
which  are  acute;  and  a  small  clot  of  fibrin  usually 
appears  in  it  after  standing  for  some  time.  It  does 
not  usually  contain  any  reducing  substances.  The 
bacteriological  examination  of  the  fluid  is  of  special 
importance,  and  should  be  carried  out  as  in  Chapter 
XIY. 

3.  The  chief  characters  of  the  other  fluids  likely  to 
be  met  with  on  exploration  are  contained  in  the 
following  table  : — 


Table  of  Fluids. 


511 


rC 

._:,.•  CO  0!  +j  Si 

0 

03 

a  3  s  2  »=  =" 

Ha 

-1 

T-H 

T 

0 

4^ 

-c;  03         o)  oi  '■" 

^  c  ■«     ^  —  5 

< 

0^ 

0 

j^3qSsS."S 

0 

H    . 
■<)  -n 

pa  H 
pjto 

0 
m  si 

>> 

2t 

;3 

.«     ^             ?     03     _i  -w 

CI, 

5 
"S 

0 

.2 

a-TJ^ie  03  5-^^ 
0^  a  Q^.^;:^'^  s 

0  "^ 

^ 

j-jOcjO'CiojoiS 

< 

CO 

cite 

OJ 

0  *" 

-^ 

1 

So 

"o 

^ 

c3 

0 

0 

0 

1 

, 

«w    -•    Oj     ■     ID    J    ^     '     D 

'       >S 

1  c 

'aj 

<sS 

>5 

'^  ^ 

^i 

!-i 

._  0 

> 

m5 

tn 
0 

> 

0 

»o 
1 

(M 
0 

0 

r-T 

> 

03    0-5 

Q 

0  i) 
oj  ca 

T^  -4-* 

>3 

>> 

o3 

>a 

.2  .S  i 

pa  <;  = 

a- 

03 

0 

t3 

03 

a;  .-.   to   0) 

;-i 

>5>> 

ri       U 

X 

0 

cS  -r* 

•  1-4  •;-' 

0  00 

03    OT 

g 

S-l 

5 

-1-3  III' 

SJO 

0)  — 

0 

03 

QBj 

-S    ^ 

>j 

<M 

I 

'^ 

s  ° 

1 
CO 
0 
0 

OJ 

a  H  0 

!<i 

o^- 

^ 

^ 

c3 

:^  ==  =* 

>a 

c3   O)  be 

P3  2  M 

0; 
03 

0) 

>j 

CO 

CI 

CO 

."2    C    03 

c   °   "  S 

'0 
0 

1 

0 
i-T 

>> 

> 

2    0    t<    M 

03 

S>> 

+3 

>3 

0  c 

M 

■0 

>5 

a:> 

0 

<D    03-2 
0    03    O) 

-0 

w 

CO 

a; 

a 

0 

1 

CO 

(O  0  0 

£  °  2 

0 

eS     : 

Oi 

CO 

H 

|3 

CS 

03 

"2 

03 

C3 

0 

'm 

%^ 

5d 

0 

®    ^ 

E3 

c3 

u. 

pHrfl 

'0 

0 

p<> 

0 

Ph 

0 

0 

0 

OQ 

0 

OQ 

5^2 


CHAPTER    XIV. 

Clinical  Bacteriology. 

In  order  to  make  a  complete  bacteriological  examina- 
tion, three  methods  of  observation  are  necessary. 
These  are  microscopic  study  of  the  oi'ganisms,  their 
cultivation  on  suitable  media,  and  the  effects  produced 
by  their  inoculation  into  various  animals.  To  obtain 
material,  and  to  carry  out  the  subsequent  examination, 
the  following  instruments,  all  of  which  must  be 
thoroughly  sterilised  immediately  before  use,  are 
required  : — 

1.  Pl£&tiniiiii  needles,  about  3  in.  in  length 
and  sutficiently  stout  not  to  bend  very  readily,  fused 
into  glass  handles.  Some  of  these  should  have  their 
ends  curved  into  a  small  loop,  others  ought  to 
have  the  last  half  centimetre  bent  at  riglit  angles 
to  the  rest  of  the  wire,  whilst  a  few  should  remain 
straight  and  have  their  free  extremity  somewhat  flat- 
tened like  a  narrow  spatula. 

2.  Small  sterile  pipettes. — For  clinical  use, 
ordinary  vaccination  tubes,  carefully  sterilised  and 
then  sealed  off,  are  very  serviceable.  A  few  larger 
ones  are  also  needed. 

3.  Swabs  for  collecting  particles  from  false  mem- 
branes. To  make  these,  a  piece  of  stiff  copper 
wire,  about  18  B.W.G.  in  thickness,  should  be  em- 
ployed. A  portion  7  in.  long,  should  have  a  flat 
loop  made  at  one  end,  round  which  a  small  piece 
of  absorbent  cotton  wool  must  be  firmly  twisted. 
Wool  must  not  be  used  that  lias  been  rendered  anti- 
septic with  mercuric  chloride  or  other  disinfectant. 
A  test  tube   about  an  inch  shorter  than  the  wire  is 


Appa 


RA  TUS.  513 


then  selected,  and  its  mouth  plugged  with  a  stopper 
of  cotton  wool,  through  which  the  wire  passes.  There- 
after the  tube  with  its  contained  swab  is  carefully 
sterilised  by  heat.  Several  such  swabs  should  be 
taken  to  the  patient,  and,  after  having  been  used  to 
collect  the  material  which  requires  examination,  can 
be  replaced  in  their  test  tubes  and  brought  back  to 
the  laboratory  without  fear  of  contamination. 

4.  A  hj'poderinic  syringe  which  can  be  steril- 
ised by  boiling.  One  which  the  writers  have  found 
convenient  is  designed  by  Strauss  and  sold  by  Collin, 
of  Paris.  The  plunger  is  made  of  elder  pith,  and  by 
a  simple  adjustment  can  readily  be  fitted  to  the  piston 
rod,  and  the  other  joints  are  also  rendered  secure  by 
discs  of  the  same  substance.  Boiling  improves  rather 
than  injures  the  pith  fittings,  and  when  one  has  worn 
out  a  new  disc  can  easily  be  cut  with  a  penknife 
from  a  piece  of  fresh  pith. 

In  order  to  make  a  complete  examination  of  the 
materials  obtained  by  the  above  means  a  small 
laboratory  is  required.  In  it  there  should  be 
ovens  for  sterilising  the  different  pieces  of  appa- 
ratus by  dry  heat  and  by  steam,  and  if  cultures 
are  to  be  made,  an  incubator  must  also  be  obtained. 
For  many  purposes,  and  especially  for  the  detection 
of  bacteria  in  urine  and  in  serous  effusions,  a 
centrifuge  is  practically  essential,  whilst  a  Bunsen 
burner,  capsules,  watch  glasses,  forceps,  slides,  cover 
slips,  a  good  microscope,  stains  and  reagents,  test 
tubes,  beakers,  flasks,  funnels,  and  filter  paper  are 
also  required. 

The  capsules  should  be  of  porcelain,  nickel,  or 
platinum,  and  should  be  employed,  wherever  heat  has 
to  be  applied  to  staining  fluids,  in  place  of  watch 
glasses,  which  crack  readily.  Metal  capsules  should 
be  scrupulously  washed^  and  then  sterilised  by  heating 
to  redness  in  a  flame.     Porcelain  ones  should  also  be 

H    H 


514  Cl  I  NIC  a  l    Ba  cteriol  og  y. 

sterilised  by  heat,  and  must  not  be  used  after  tliey 
become  cracked. 

Slides  aii€l  cover  g-laisses — the  latter  must  be 
thin,  preferably  No.  1 — must  be  washed  with  dilute 
nitric  acid,  afterwards  with  ammoniated  water,  and 
then  with  alcohol.  Thereafter  they  may  be  kept  in 
a  covered  vessel  under  alcohol  until  they  are  required. 

The  most  generally  useful  forceps  for  holding 
cover  glasses  are  those  known  as  Cornet's.  In  these 
the  spring  is  so  arranged  that  the  cover  glass  is  firmly 
held  until  released  by  pressure,  and  the  blades  are 
constructed  so  that  the  cover  slip  is  in  a  horizontal 
position  when  the  forceps  is  laid  down. 

'ihe  stains  which  are  most  employed  belong  to 
the  basic  aniline  dyes,  and  are  either  simple  aqueous 
and  alcoholic  solutions,  or  contain  a  mordant,  such  as  an 
alkali,  carbolic  acid,  or  aniline  oil,  which  makes  the  bac- 
teria take  up  the  stain  better  and  retain  it  more  firmly. 
Most  of  these  dyes  are  so  used  that  the  preparation  is 
first  overstained  and  then  the  excess  washed  out  by 
suitable  reagents,  when,  owing  to  the  greater  tenacity 
with  which  bacteria  cling  to  the  colouring  matter, 
they  remain  clearly  visible  after  all  else  has  become 
partially  decolorised.  A  few  stains,  however,  one  of 
the  most  important  of  which  is  Bismarck  brown,  are 
employed  differently ,  as  their  selective  action  is  so 
marked  from  the  very  outset,  and  their  tendency  to 
overstain  is  so  slight,  that  there  is  no  need  of  securing 
differentiation  by  the  more  tedious  method  of  over- 
staining  and  then  washing  out.  Such  stains  generally 
act  with  fair  rapidity. 

For  most  purposes  the  following  stains  suffice  : — 

1.  Fuchsin      ...  ...  saturated  alcoholic  solution. 

2.  Gentian  violet  . . .  saturated  alcoholic  solution. 

3.  Methylen  blue  ...  saturated  watery  solution. 

4.  Bismarck  brown  ...  ...  aqueous  solution. 


Stains.  515 

5.  Loffler's  stain  ...  ...  \ 

6.  Ziehl-Neelsen's  stain  [for  tubercle]    (  see  Appendix, 

7.  Carboltliionine        ...  ...  C        20-23. 

8.  Gram's  reagents     ...  ...  ) 

9.  Ronx's  stain  [for  diphtheria]  (see  p.  524). 

The  stains  must  not  be  kept  too  long,  must  be  fre- 
quently filtered,  and  should  be  examined  from  time  to 
time  for  bacteria,  which  occasionally  invade  them — es- 
pecially when  the  solutions  are  aqueous — and  unless 
detected  may  lead  to  serious  mistakes. 

For  mounting  the  specimens  one  may  employ  Far- 
rant's  medium  if  the  slide  is  not  to  be  permanentl}" 
preserved,  otherwise  Canada  balsam  in  xylol  should 
be  used.  It  is  very  important  to  remember  that  some 
stains  make  bacteria  look  larger  than  others  do,  and 
also  that  their  apparent  size  is  less  when  they  are 
mounted  in  balsam  than  when  the  examination  is 
made  with  a  drop  of  water  or  with  Farrant's  medium. 
When  cultures  are  desired,  tubes  containing  nutrient 
gelatin,  blood  serum,  agar-agar,  and  glycerine  agar, 
and  flasks  of  bouillon  must  be  provided.  These  can 
occasionally  be  obtained  from  dealers,  but  are  better 
prepared  in  a  well  equipped  laboratory.  The  details 
of  preparation  are  outside  the  scope  of  this  text-book. 

The  method  of  exaniiiiatioii  which  is  most 
readily  available  in  clinical  work  is  the  preparation  of 
Alms  on  cover  slips.  The  technique  is  as  follows : — 
A  cover  slip,  which  must  be  thin  enough  to  admit  of 
the  film  being  examined  through  it  by  an  oil  immersion 
lens,  and  which  is  thoroughly  clean,  is  taken,  and  a 
very  small  drop  of  the  fluid  under  examination  is 
spread  over  it  in  a  thin  layer  by  a  sterilised  platinum 
needle.  If  the  material  is  too  solid,  as  may  be  the  case 
when  cheesy  particles  are  being  examined,  a  drop  of 
distilled  water  must  be  added  and  intimately  mixed 
with  the  niass  before  the  cover  slip  is  smeared  with  it. 
The  excess  of  fluid  is  then  allowed  to  evaporate  by 


5i6  Clinical   Bacteriology. 

holding  the  preparation,  fihn  upwards,  some  height 
above  a  flame,  and  the  dry  film  is  "  fixed  "  by  passing 
it  thrice  through  a  Bunsen  or  spirit  flame,  film  upwards, 
at  such  a  rate  that  each  transit  occupies  something  less 
than  a  second. 

Thereafter,  in  order  to  make  the  background  stain 
less  deeply,  it  is  immersed  for  one  minute  in  a  1  per 
cent,  aqueous  solution  of  acetic  acid.  It  is  then 
quickly  dried,  and  fixed  in  the  forceps,  film  upwards. 
A  test  tube  is  taken  and  half  filled  with  distilled 
water,  and  the  selected  stain,  which  should  have  been 
recently  filtered,  is  added  until  the  fluid  is  just  trans- 
parent. Take  up  a  few  drops  of  the  dilute  stain  with 
a  pipette  and  apply  it  to  the  film.  After  the  lapse  of 
a  couple  of  minutes  wash  the  slip  with  water,  dry  it 
thoroughly,  and  mount  in  xylol  balsam. 

The  specimen  must  be  examined  with  a  high- 
power  objective.  In  most  instances  an  oil  immersion 
lens  of  yV  inch  focus  should  be  used,  although  in  many 
cases  a  lower  power,  such  as  a  Zeiss  D  objective,  may  be 
sufficiently  strong  for  clinical  purposes.  The  micro- 
scope should  be  provided  with  an  Abbe  condenser 
the  diaphragm  of  which  must  be  used  fully  opened,  and 
the  plane  mirror  employed  to  reflect  the  light.  The 
inner  tube  of  the  microscope  should  be  drawn  out  to 
the  length  for  which  the  objective  is  constructed. 
Continental  objectives  mostly  work  to  best  advantage 
with  a  tube  length  of  160  mm.  English  objectives 
require  a  tube  length  of  10  inches. 

In  using  the  oil  immersion  lens,  a  drop  of  prepared 
cedar  oil  is  placed  on  the  cover-glass,  and  the  objective 
lowered  by  the  hand  or  coarse  adjustment  until  it 
touches  the  surface  of  the  oil ;  the  focussing  is  then 
carefully  performed  with  the  fine  adjustment.  As 
the  lens  is  delicate  and  the  working  distance  small, 
great  care  must  be  taken  not  to  bring  the  lens  and 
cover  glass  into  contact ;  and  when  the  observation  is 


Inoculation  of  Tubes.  517 

completed  the  cedar  oil  must  be  gently  \idped  from 
the  surface  of  the  objective  with  a  piece  of  old  silk. 

When  a  tube  requires  to  be  inoculated  the  follow- 
ing procedure  should  be  adopted  : — 

The  tube  containing  the  pathological  fluid  is  held 
between  the  thumb  and  first  finger  of  the  left  hand, 
so  that  the  mouth  with  its  stopper  of  cotton  wool  is 
on  the  palmar  side.  The  tube  to  be  inoculated  is 
similarly  held  between  the  first  and  second  fingers 
of  the  same  hand,  with  the  surface  of  the  nutrient 
medium  upwards.  Both  tubes  should  be  held  as 
horizontally  as  possible  short  of  wetting  the  stoppers 
with  the  contents.  A  platinum  needle  is  then  taken 
in  the  right  hand,  thoroughly  sterilised  by  heating  to 
bright  redness,  and  allowed  to  cool  again.  The 
stopper  of  the  specimen  tube  is  then  withdrawn  by 
the  right  hand  and  placed  between  the  fourth  and 
fifth  fingers  of  the  left  hand,  and  finally  the  stopper 
of  the  nutrient  tube  is  withdrawn  and  retained 
between  the  fingers  of  the  right  hand,  care  being 
taken  that  the  stoppers  are  only  held  by  their 
external  ends.  The  needle  is  then  dipped  into  the 
specimen,  and  the  smallest  trace  of  it  is  withdrawn 
and  transferred  to  the  surface  of  the  nutrient  medium, 
along  which  a  streak  is  drawn.  The  tubes  are 
at  once  re-stoppered,  the  needle  again  sterilised, 
and  the  culture  placed  in  an  incubator  as  soon  as 
convenient. 

Where  micro-organisms  are  very  abundant  in  the 
specimen,  several  tubes  should  be  successively  in- 
oculated without  recharging  the  needle.  In  this 
way,  though  the  growth  is  excessive  in  the  first,  in 
the  third  or  fourth  the  colonies  are  more  scattered, 
and  pure  cultures  may  be  separated  out. 

A  cheap  metal  pen  rack  is  a  convenient  support  on 
which  to  lay  the  needle  after  it  has  been  sterilised, 
when  a  number  of  tubes  are  being  dealt  with. 


5i8  Clinical   Bacteriology. 

Special  Methods. 

1.  Spiituni. — The  sputa  which  are  of  the 
greatest  importance  bacteriologically,  are  those  of 
pneunionia  and  of  phthisis.  In  pneumonia  the 
diplococci  are  most  readily  found  when  the  disease 
is  at  its  height.  Select  a  rust-coloured  portion  of 
sputum,  spread  it  in  as  thin  a  film  as  possible,  dry, 
fix,  and  stain  with  the  fuchsin  solution  employed  for 
tubercle  bacilli  as  recommended  by  Ziehl.  Decolorise 
by  means  of  warm  water.  Tf  successful,  the  cocci 
will  be  darkly  stained,  and  the  surrounding  capsule 
will  appear  in  a  fainter  shade  of  red. 

In  tubercular  sputum  much  of  the  success  depends 
on  the  choice  of  a  suitable  specimen.  The  sample 
should  be  chosen  from  the  interior  of  one  of  the 
mucopurulent  masses  that  are  seen  underneath  the 
serous  fluid  portion.  If  the  mass  is  so  tenacious  that 
a  suitable  piece  will  not  adhere  to  the  needle,  spread 
the  sputum  in  a  shallow  glass  vessel  and  either  pick 
out  the  part  required  with  sterilised  forceps  or  plunge 
a  hot  needle  into  the  mass,  when  a  portion  will 
adhere  to  it ;  care  must  be  taken  not  to  use  the 
central  charred  mass.  When  the  sputum  comes  from 
a  phthisical  cavity  it  may  contain  almost  pure 
cultures  of  tubercle  bacilli  in  its  interior,  though  the 
outer  surface  of  the  mass  is  naturally  contaminated 
during  its  passage  through  the  mouth.  To  prevent 
confusion  from  spread  of  contamination,  the  sputum 
ought  always  to  be  examined  as  soon  as  possible 
after  it  has  been  expectorated.     (Frontispiece,  6.) 

In  cases  of  hsemoptysis  the  best  specimens  in 
which  to  seek  for  bacilli  are  often  the  small  dark 
red  clots  that  are  coughed  up  a  day  or  two  after  the 
attack  has  suljsided. 

In  acute  miliary  tuberculosis  without  typical 
tubercular  sputum,  it  may  be  almost  impossible  to 
demonstrate  the  presence  of  the  bacilli. 


Sputum.  519 

In  difficult  cases  the  sputum  should  be  heated 
with  caustic  soda  and  water  till  a  homogeneous  fluid 
is  produced.  This  is  set  aside  for  thirty-six  hours  in 
a  conical  test  glass  and  the  sediment  examined,  or  the 
sedimentation  may  be  more  rapidly  effected  by  a 
centrifuge. 

When  a  suitable  specimen  has  been  obtained,  it 
should  be  spread  very  thinly  and  evenly  on  a  cover 
glass,  and  allowed  to  dry  in  the  air  at  the  temperature 
of  the  room.  When  it  is  quite  dry,  it  is  taken  in 
a  forceps  and  passed  several  times  rapidly  through 
a  smokeless  flame,  as  has  been  already  described, 
to  coagulate  the  albuminous  materials,  and  so  fix 
the  film  to  the  glass.  It  should  then  be  placed 
film  downwards  on  the  top  of  a  little  carbol-fuchsin 
stain  contained  in  a  capsule,  and  the  fluid  heated 
till  steam  rises.  Generally,  it  is  well  to  repeat 
the  heating  three  or  four  times.  Then  wash  in  water 
and  decolorise  in  a  20  per  cent,  solution  of  sulphuric 
acid  until  all  the  elements  except  the  bacilli  have 
parted  with  the  stain.  As  a  rule,  this  is  accomplished 
in  from  one  to  three  minutes.  Wash  once  more  in 
water,  dr}^,  and  mount  either  in  a  drop  of  Farrant's 
medium  if  the  specimen  is  not  to  be  kept  for  any 
length  of  time,  or  in  Canada  balsam  dissolved  in 
xylol  if  a  more  permanent  preparation  is  required. 

The  specimen  must  be  examined  with  a  high 
power  and  good  illumination  ;  by  preference  with  an 
oil  immersion  lens  and  Abbe  condenser — though  for 
clinical  work  a  lower  power  is  often  sufficient. 

Many  workers  prefer  to  counterstain  with  a 
watery  solution  of  methylen  blue  for  one  minute. 
This  has  the  advantage  of  revealing  the  other  elements 
present  in  the  sputum,  and  the  disadvantage  of 
making  the  detection  of  the  tubercle  bacilli  rather 
more  difficult. 

2.  Blood.  —  This  ^may   be  readily  examined  by 


5  2  o  Clinic  A  l   Ba  cteriology. 

careful  sterilisation  and  subsequent  pricking  of  the 
finger-tip,  so  as  to  make  a  drop  of  blood  exude 
with  which  to  prepare  films  on  cover  glasses.  Since 
it  is  often  very  difiicult  to  obtain  complete  disin- 
fection of  the  skin,  an  alternative  method  may  be 
adopted,  and  blood  aspirated  from  a  vein  in  the  arm 
by  means  of  a  syringe.  This  method  has  the  ad- 
vantage of  securing  a  larger  quantity  of  blood,  and 
should  be  employed  when  inoculations  are  to  be 
undertaken.  Puncture  of  the  spleen  has  been  advo- 
cated on  the  Continent,  but  it  may  lead  to  unpleasant 
symptoms."^ 

When  the  film  of  blood  has  been  made  on  the 
cover  glass,  it  must  be  well  dried  in  warm  air  before 
it  is  passed  througli  the  fiame,  and  thereafter  should 
remain  for  some  time,  best  for  three  or  four  hours,  in 
an  oven  at  a  temperature  of  120^  C.  Before  applying 
the  stain  a  preliminary  immersion  in  dilute  acetic 
acid  assists  both  in  discharging  the  colour  of  the 
red  blood  corpuscles  and  in  accentuating  the  different 
affinities  of  the  bacteria  and  blood  elements  for  the 
dye ;  it  must,  however,  be  carefully  washed  off,  and 
the  last  traces  of  it  neutralised  by  ammonia  vapour 
before  staining  is  proceeded  with. 

The  stains  which  prove  most  useful  are  Gram's, 
Loffler's,  or  alcoholic  fuchsin.  When  the  stain  is 
blue,  watery  eosin  may  be  used  as  a  counterstain  to 
bring  out  the  red  blood  corpuscles. 

3.  Urine  may  be  examined,  after  careful  disinfec- 
tion of  the  meatus,  either  by  drawing  off  a  sample  from 
the  bladder  with  a  sterile  catheter,  or  by  making  the 
patient  pass  water,  and,  after  the  first  portion  of 
the  urine  has  cleansed  the  urethra,  collecting  the 
remainder.     The  centrifuge  should  be  invariably  used 

*  Similarly  some  observers  have  punctured  the.  lungs,  liver,  and 
other  organs  to  secure  luicontaminated  samples  of  the  bacteria 
which  they  contained. 


Urine.  521 

to  secure  a  deposit  without  delay,  and  the  latter  then 
examined. 

One  of  the  most  important  bacteria  that  may 
be  found  in  the  urine  is  the  tubercle  bacillus.  The 
pus  which  is  separated  from  the  suspected  urine  is 
spread  not  too  thinly  on  a  cover  glass,  which  is  then 
manipulated  in  the  manner  already  described  for 
tubercular  sputum.  In  cases  where  the  sediment 
contains  small  purulent-looking  lumps,  these  should 
be  selected  to  smear  on  the  cover  glass.  If  the  urine 
is  loaded  with  urates  they  may  be  readily  dispelled  by 
adding  warm  water  to  the  sediment,  or  by  washing 
the  film  with  warm  water  before  staining. 

The  bacilli  when  found  frequently  occur  in  clumps, 
whilst  it  may  be  necessary  to  examine  six  or  more 
preparations  before  a  clump  is  discovered. 

One  of  the  chief  sources  of  fallacy  in  examining 
for  tubercle  bacilli  results  from  the  presence  of  the 
smegma  bacillus,  which  has  very  similar  morpho- 
logical characteristics,  and  especially  resists  the  de- 
colorising action  of  sulphuric  and  nitric  acids.  To 
distinguish  them  the  cover  slip  should  be  immersed 
for  ten  minutes  in  a  solution  of  hot  caustic  soda  to 
which  5  per  cent,  of  alcohol  has  been  added.  The 
specimen  is  thereafter  washed  with  water  and  absolute 
alcohol.  Tubercle  bacilli  thus  treated  still  retain 
the  stain  when  exposed  to  the  action  of  mineral  acids, 
whilst  the  smegma  bacillus  is  decolorised. 

In  cases  of  cystitis  the  most  commonly  found 
organisms  are  the  bacterium  coli,  the  gonococcus,  and 
the  tubercle  bacillus.  In  some  instances,  especially 
in  women  or  in  persons  on  whom  catheters  have  been 
passed,  the  ordinary  staphylococci  of  suppuration  are 
also  present  in  large  numbers. 

In  urethritis  resulting  from  gonorrhoeal  infection 
the  gonococcus  is  present,  but  is  often  associated 
with  numerous  other  dijDlococci,  wliich  are  not  very 


522  Clinical   Bacteriology. 

readily  distinguished  from  it.  Since  it  is  of  import- 
ance medically  as  the  cause  of  certain  affections 
which  resemble  rheumatism,  it  is  necessary  to  be  able 
to  recognise  it.  Films  may  be  made  in  the  ordinary 
way,  stained  lightly  with  watery  solution  of  methylen 
blue,  again  washed  and  examined  in  water,  or  dried 
and  permanently  mounted.  The  organism  will  be 
described  subsequently. 

4.  Pms  and  other  fluid  exudations  are  best 
obtained  by  aspiration  from  the  cavity  in  which  they 
lie  with  a  sterile  hypodermic  syringe,  after  thorough 
disinfection  of  the  skin  where  the  needle  is  to  be 
inserted.  Amongst  the  most  important  of  such 
exudations  are  those  into  the  pleural  cavities.  These 
may  either  be  serofibrinous  or  purulent.  In  nearly 
three-fourths  of  the  cases  of  empyema  which  have 
been  examined,  the  organisms  that  have  been  found 
are  either  pneumococci,  staphylococci,  or  streptococci, 
and  in  the  case  of  adults  the  last  constitute  fully 
half  of  the  total.  In  children  the  pneumococcus 
preponderates.  As  regards  prognosis,  the  presence 
of  streptococci  gives  much  the  gravest  outlook,  and 
this  agrees  with  the  relatively  favourable  issue  of  the 
disease  in  children. 

5.  Specimens  from  false  membranes  are  best 
obtained  by  removing  a  small  portion  with  a  swab  or 
forceps.  Care  must  be  taken  not  to  touch  any  other 
part  of  the  patient's  mouth  with  the  swab.  In  cases 
of  suspected  diphtheria  it  often  happens  that  so 
many  organisms  are  present  on  the  surface  of  the 
membrane  that  it  is  almost  impossible  to  identify 
the  bacillus  of  diphtheria  amongst  the  other  bacteiia 
which  are  associated  with  it.  Under  these  conditions 
the  piece  of  membrane  should  be  washed  in  a  flask 
with  a  little  boiled  water.  After  being  agitated  in 
this  for  a  short  time,  the  cocci,  mucus,  and  other 
adventitious    elements  which    have    adhered    to    the 


Chief  Bacteria.  523 

surface  become  for  the  most  part  detached,  and  the 
specific  organism  can  thereafter  be  obtained  in  a 
much  purer  condition  by  thrusting  a  platinum  needle 
into  the  membrane  after  its  removal  from  the  flask, 
and  inoculating  several  tubes  successively  without 
recharging. 

6.  Faeces. — The  faeces  are  always  rich  in  micro- 
organisms ;  it  is  therefore  of  great  importance  to 
lift  only  a  very  minute  fragment  for  examination, 
whether  on  the  slide  or  by  cultures. 

The  following  are  the  most  important  bacteria 
from  the  point  of  view  of  clinical  examination : — 


I. — Bacilli. 

(a)  Bacillus  tuberculosis. — It  is  rather  small 
and  slender  (2  to  5  \x  in  length).  As  seen  in  sputum 
it  is  not  infrequently  a  little  curved ;  and  often  two 
bacilli  are  found  lying  end  to  end,  making  an  obtuse 
angle  with  one  another.  The  staining  may  be 
uniform,  or  there  may  be  small  clear  spaces  of  an 
ovoid  form  which  are  disposed  at  intervals.  It  is 
best  stained  by  Ziehl's  method. 

(6)  Pfeiffer's  bacillus  is  a  minute  bacillus  with 
rounded  extremities ;  the  ends  stain  more  deeply 
than  the  centre.  It  is  not  coloured  by  Gram's 
method,  but  can  be  demonstrated  by  Ziehl's  stain. 
It  is  found  in  the  sputum,  and  occasionally  in  the 
blood  of  patients  suffering  from  influenza. 

(c)  Bacillus  diplittieriae  (Klebs-Loffler). — This 
bacillus  aA^erages  about  3  \i  in  length,  the  long  variety 
considerably  more,  and  -6  or  -7  /x  in  breadth.  The 
ends  are  rounded  and  rather  stouter  than  the  centre, 
and  stain  more  deeply  ;  frequently  there  is  unequal 
staining  of  the  protoplasm.  (Froxtispiece,  «,  a!.) 
In  most  instances  they  are  very  readily  coloured  by 


524  Clinical   Bacteriology. 

Gram's  method,  but  for  demonstration  the  best  stain 
is  that  suggested  by  Roux,  which  is  as  follows  : — 

1  per  cent,  aqueous  solution  of  dahlia,  1  part. 
1  per  cent,  aqueous  solution  of  methyl  green,  3  parts. 
Distilled  water,  till  the  fluid  appears  of  a  moderately  deep 
blue  colour. 

The  procedure  which  should  be  adopted  in  cases 
where  a  patient's  throat  is  to  be  examined  for 
the  bacillus  of  diphtheria,  is  as  follows :  Set  the 
patient  in  a  good  light.  Depress  the  tongue  with  the 
handle  of  a  spoon ;  then  take  a  swab,  pass  it  to  the 
back  of  the  mouth  without  touching  the  lips,  gums, 
or  tongue,  and  press  it  gently  against  the  suspected 
patch  on  the  tonsil.  By  rotating  the  swab  a  portion 
of  the  false  membrane  is  entangled  and  brought 
away,  and  the  specimen  thus  obtained  is  returned  to 
the  tube  and  taken  to  the  laboratory.  A  cover-glass 
preparation  may  be  made  directly  from  it,  but  is 
likely  to  prove  unsatisfactory,  as  many  different 
organisms  are  so  abundantly  present  that  it  is  seldom 
possible  to  detect  the  Klebs-Loffler  bacillus  with 
certainty.  To  start  cultures,  a  platinum  needle, 
previously  sterilised  and  allowed  to  cool,  is  charged 
from  the  false  membrane,  and  four  tubes  are  succes- 
sively inoculated  from  the  needle,  which  is  drawn  in 
a  streak  along  the  surface  of  each  without  recharging. 
By  far  the  most  satisfactory  medium  is  blood  serum. 
Gelatin  and  glycerin-agar  are  untrustworthy,  and 
should  never  be  employed  for  diagnostic  cultures  of 
the  diphtheria  bacillus.*  After  inoculation  the  tubes 
are  placed  in  an  oven  at  37°  C.  If  the  Klebs-Loffler 
bacillus  is  present,  growth  will  often  be  manifest  in 

*  Failing  blood  serum,  a  medium  composed  of  agar-agar  pre- 
pared with  ascitic,  pleuritic,  or  hydrocele  fluid,  containing  2 
per  cent,  of  a  10  per  cent,  solution  of  caustic  potash,  with  5 
per  cent,  glycerin,  and  1  per  cent,  grape  sugar,  as  recom- 
mended by  Kanthack,  may  be  tried. 


Bacillus  of  Diphtheria.  525 

eighteen,  and  always  in  twenty-four  hours,  by  which 
time  the  colonies  in  the  third  and  fourth  tubes  will  be 
as  large  as  pinheads.  In  colour  they  are  dull  white, 
and  ap[)ear  distinctly  denser  in  the  centre  when  viewed 
by  transmitted  light.  The  colonies  are  circular,  and 
spread  rather  rapidly.  In  the  first  and  second  tubes 
the  characters  are  not  so  well  seen,  because  the 
colonies  are  so  numerous  that  they  rapidly  fuse  and 
so  lose  their  contours.  Specimens  obtained  from 
the  individual  colonies  must  be  microscopically 
examined,  and  pure  cultures  can  be  started  from 
some  of  them  by  mixing  them  with  a  little  bouillon, 
and  reinoculating  serum  tubes  with  the  product. 

In  doubtful  cases  the  diagnosis  may  be  established 
only  after  inoculations  have  been  performed. 

Occasionally,  when  the  membrane  is  peculiarly 
rich  in  adventitious  bacteria,  it  may  be  necessary 
to  place  it  in  a  tlask  with  some  boiled  water  and 
to  treat  it  in  the  manner  described  above,  before 
proceeding  to  inoculate  the  tubes. 

When  information  is  sought  regarding  other 
bacteria  which  may  also  be  present  in  the  specimen, 
it  is  best  to  break  up  a  small  fragment  in  bouillon  and 
inoculate  various  culture  media  with  a  drop  of  the  fluid. 

In  practice  one  finds  that  sometimes  the  mem- 
brane contains  a  preponderant  proportion  of  Klebs- 
Loffler  bacilli  ;  in  many  cases,  however,  other  bacteria 
occur  in  large  numbers  along  with  it,  streptococci 
being  frequently  present,  particularly  in  severe  cases. 
In  other  instances  a  form  of  diplococcus  has  been 
observed. 

In  addition  to  the  typical  form  of  Klebs-Lofiier 
bacillus  there  is  a  stunted  form  which  is  shorter  and 
more  irregular  in  outline.  One  cannot,  however, 
estimate  with  any  certainty  the  toxicity  of  a 
.  specimen  from  its  morphological  characters,  nor,  on 
the   other  hand,  is  one  justified  in  considering  that 


526  Clinical    Bacteriology. 

the  bacillus  is  not  a  true  diplitlieria  bacillus  because 
it  happens  to  be  devoid  of  virulence,  although  the 
intensity  of  its  toxin  will  obviously  influence  the 
clinical  history  of  the  case  from  which  it  is  derived. 
It  is  not  therefore  expedient  to  classify  such  non- 
virulent  bacteria  as  "pseudo-diphtheritic,"  since 
experience  has  shown  that  the  virulence  of  diphtheria 
bacilli  may  vary  exceedingly  even  when  they  have 
sprung  from  a  common  source. 

The  term  "pseudo-diphtheritic  bacillus  "  has  also 
been  applied  to  various  bacteria  whose  morphology 
is  almost  identical  with  the  true,  but  which, 
under  the  tests  of  culture  and  inoculation,  are  found 
to  deviate  more  or  less  from  the  latter.  Used  in  this 
sense  the  term  is  convenient,  if  not  strictly  accurate. 

{d)  Bacillus  of  typhoid  (Eberth).  — This 
organism  can  be  obtained  in  the  spleen  during  the 
course  of  the  disease,  and  from  the  blood  in  the  rose- 
coloured  spots.  It  also  occurs  in  the  urine  if 
albuminous,  and  in  the  stools.  It  is  mobile,  and  by 
suitable  methods  flagella  can  be  demonstrated.  The 
ends  are  rounded,  the  length  3  or  4  /i.,  the  breadth 
about  1  /^.  It  does  not  stain  by  Gram's  method,  but 
is  readily  coloured  by  the  ordinary  aniline  basic  dyes. 

In  arriving  at  an  early  diagnosis  of  typhoid  fever 
l¥idal's  test  seems  likely  to  take  a  very  prominent 
position.       It  is  based  on  the  fact  that  after  a  certain 


Fig.  136. — Widal's  pipette.    Actual  size. 

time  has  elapsed  the  blood  serum  of  a  typhoid  patient 
acquires  a  power  of  interfering  with  the  ordinary 
behaviour  of  the  bacillus,  and  it  is  conducted  as 
follows"^  : — 

*  The  method  is  taken  from  Sheridan  Delepine's  ijajjer   in  the 
British  Medical  Journal  for  April  17th,  1897,  p.  967. 


Bacillus  of  Typhoid,  527 

1.  Apparatus* 

(a)  A  small  lancet-shaped  needle  to  obtain  blood. 
This  must  be  capable  of  ready  sterilisation. 

(5)  A  sterile  pipette  to  collect  the  blood  and 
transmit  it  to  the  laboratory ;  it  must  be  wide 
enough  to  admit  the  loop  (Fig.  136). 

(c)  A  platinum  needle  ending  in  a  loop  of  1mm. 
diameter.      (This  will  lift  about  2  mgms.  of  fluid.) 

(d)  A  sterilised  slide  and  cover  glass. 

(e)  A  tube  of  bouillon  containing  a  culture  of 
typhoid  bacillus  not  more  than  twenty-four  hours  old. 
The  tube  must  be  free  from  clumps  of  bacilli,  and 
the  latter  must  exhibit  active  movements  on  micro- 
scopic examination. 

(y)  A  microscope  capable  of  magnifying  at  least 
250  diameters  (preferably  from  300  to  400  diameters) 
should  be  used,  though  even  with  lower  powers  a 
good  deal  may  be  made  out. 

2.  Method. 

{a)  Carefully  sterilise  the  patient's  finger,  and 
obtain  several  drops  of  blood  by  a  prick  in  the  thin 
skin  near  the  root  of  the  nail.  The  blood  is  drawn 
into  the  pipette,  which  is  then  sealed  off  and  taken  to 
the  laboratory. 

(6)  Take  nine  loopfuls  of  the  turbid  bouillon  and 
deposit  them  separately  on  the  microscope  slide,*  then 
again  sterilise  the  loop  and  let  it  cool. 

(c)  Break  off  the  sealed  ends  of  the  pipette, 
remove  one  loopful  of  blood  serum,  and  deposit  it  also 
on  the  slide.  This  will  contain  some  corpuscles,  but 
their  presence  will  not  cause  any  inconvenience. 

id)  Mix  the  serum  as  rapidly  as  possible  with  the 
bouillon,   apply  the  cover  glass,  press  it  gently  down 

*  The  best  form  of  slide  is  one  with  a  slightly  depressed  plat- 
form surrounded  by  a  trench,  somewhat  like  the  slide  of  the 
Zeiss  hfemocytometer  (Fig.  .57).  Such  slides  can  be  obtained  from 
any  dealer  in  microscopic  apparatus. 


528  Clinical   Bacteriology. 

to  obtain  a  thin  uniform  film,  and  examine,  pre- 
ferably with  a  magnification  of  300  to  400  diameters. 
If  the  serum  be  taken  from  a  patient  wlio  is  not  the 
subject  of  typhoid  fever,  the  bacilli  preserve  their 
motility  unimpaired,  and  continue  to  do  so  for  days  if 
the  specimen  be  suitably  preserved.  Moreover,  they 
are  diffused  with  tolerable  uniformity  through  the 
fluid,  and  show  no  distinct  tendency  to  form  clumps. 

If,  however,  the  serum  be  taken  from  a  patient 
after  the  first  week  of  an  attack  of  typhoid  fever,  or 
even  on  the  third  or  fourth  day  of  the  illness,  though 
in  this  case  the  phenomena  will  be  less  distinct,  the 
following  facts  will  be  observed  : — The  motility  of 
the  bacilli  is  almost  at  once  impaired,  and  after  the 
lapse  of  a  few  minutes — two  to  five  where  the  serum 
is  fairly  potent — their  movements  wholly  cease. 
They  also  tend  to  become  agglomerated  into  clumps, 
which  in  a  typical  case  will  have  begun  to  form 
before  the  microscopic  examination  has  been  com- 
menced, and  by  the  end  of  half  an  hour  hardly  any 
solitary  bacilli  will  be  found  in  the  specimen.  Even 
where  the  serum  is  weaker,  as  occurs  in  a  certain 
proportion  of  cases  of  typhoid,  the  same  changes 
eventually  supervene,  but  they  occur  much  more 
slowly.  As  a  rule,  however,  impaired  motility  and 
a  tendency  to  form  clumps  are  distinctly  visible  within 
half  an  hour,  and  there  are  but  few  cases  in  which 
the  observations  need  to  be  extended  over  two  hours. 

A  method  similar  in  principle  to  the  above  has 
been  adopted  by  Prof.  Wright  and  Surgeon-Major 
Smith"^  in  their  investigations  on  the  differential 
diagnosis  of  typhoid  from  Malta  fever.  They  have 
further  been  able  to  prove  that  at  least  some  of  the 
Indian  fevers  are  due  to  the  same  organism(micrococcus 
melitensis)  that  Bruce  has  shown  to  be  the  cause  of 
Malta  fever. 

*  Lancet,  March  6tli,  1897,  p.  656. 


Bacilli.  529 

It  need  hardly  be  remarked  that  to  examine  a 
specimen  of  the  stools  directly  under  the  microscope, 
with  the  view  of  detecting  Eberth's  bacillus,  is  certain 
to  fail  in  its  aim. 

(e)  Bacillus  coli  is  a  ciliated  bacillus  Avhich 
appears  under  a  considerable  variety  of  forms.  It 
is  important  as  the  cause  of  some  cases  of  cystitis 
and  of  intra-abdominal  suppuration.  Some  of  its 
forms  resemble  that  of  Eberth's  bacillus,  but  can  be 
distinguished  by  the  fact  that  it  produces  fermenta- 
tion in  lactose,  in  which  process  the  medium  becomes 
acid,  as  can  be  shown  by  the  addition  of  litmus. 

(/)  Bacillus  cholerse  (Koch)  is  a  curved  vibrio 
with  a  tiagellum  at  each  end.  It  possesses  very  marked 
motility.  The  organism  is  much  smaller  than  the 
bacillus  of  tuberculosis.  Involution  forms  are  rather 
common.  It  is  readily  coloured  by  basic  aniline  dyes, 
but  is  not  stained  by  Gram's  method.   (Frontispiece,  g.) 

The  gelatin  cultures,  and  the  so-called  cholera-red 
reaction  in  broth, "^  are  very  characteristic,  and  should 
be  practised  in  case  of  doubt. 

In  examining  the  stools  of  a  suspected  case,  the 
organism  will  be  found  most  abundantly  present  in 
the  mucoid  masses.  A  film  should  be  made  from  one 
of  these,  and,  after  staining  with  dilute  Ziehl's  fluid, 
examined  with  an  oil  immersion  lens.  In  cases 
where    they   are    fairly   numerous,   and    where    their 

*  The  red  reaction  is  due  to  a  rdtrosoindol  body.  Many- 
bacteria  produce  indol  in  bouillon  ;  only  two,  the  bacillus  of  cholera 
and  the  bacillus  of  Finkler,  produce  both  indol  and  nitrites.  The 
bacillus  of  cholera  produces  these  substances  in  the  course  of  a  few 
hours  in  sufficient  amount  to  give  a  distinct  reaction,  Finkler's 
bacillus  only  after  three  or  four  days'  incubation.  The  addition  of  an 
acid  capable  of  acting  on  the  nitrites,  and  so  liberating  nitrous  acid, 
is  all  that  is  necessary  to  i)roduce  the  red  coloration ;  and  the 
best  acid  to  use  is  pure  hydrochloric,  as  it  is  less  often  con- 
taminated with  traces  of  nitrous  acid  than  are  nitric  aod  many 
samples  of  sulphuric  acid,  which  will  frequently  produce  the  red 
reaction  not  only  with  Finkler's  and  the  cholera  bacillus,  but  also 
with  all  other  bacteria  which  produce  indol, 

II 


53©  Clinical   Bacteriology. 

disposition  is  not  too  much  interfered  with  by  the 
simultaneous  existence  of  other  organisms,  they  will 
be  seen  to  lie  in  rows,  end  to  end  and  all  pointing 
in  the  same  direction  like  fish  in  a  stream. 

Equally  characteristic  is  the  appearance  when 
a  drop  of  the  suspected  stool  is  added  to  2  cc.  of 
a  decidedly  alkaline  solution  of  1  part  of  sodium 
chloride  and  10  parts  of  peptone  in  100  parts  of 
water.  After  eight  to  twelve  hours'  incubation  at 
a  temperature  of  37°  0.  an  abundant  growth  of  the 
cholera  bacillus  will  be  found  on  the  surface  of  the 
fluid,  and  from  it  plate  cultures  may  be  made. 

[g)  Bacillus  aiithracis. — This  organism  affects 
certain  classes  of  persons,  especially  wool  sorters.  Its 
appearance  varies  considerably  with  the  medium  in 
which  it  is  flourishing.  When  found  in  the  blood  it 
consists  of  straight  rods  fully  as  long  as  a  red  blood 
corpuscle  ;  often  two  or  more  are  arranged  end  to  end, 
either  in  a  straight  line  or  slightly  inclined  to  each 
other.  It  stains  readily  and  is  coloured  by  Gram's 
method. 

(A)  Spirillum  Otoeruieieri. — These  spirilla  are 
the  cause  of  relapsing  fever.  They  can  be  obtained  in 
the  blood  only  during  the  period  of  the  attack,  and 
wholly  disappear  in  the  intervals.  When  examined 
fresh,  they  exhibit  movements ;  they  can  also  be 
demonstrated  in  film  preparations  if  stained  with  a 
basic  aniline  dye  and  the  blood  corpuscles  counter- 
stained  with  cosine.  The  spirilla  are  from  20  to  over 
30  /i  in  length. 

{i)  Tetauus,  glanders,  and  numerous  other 
rarer  diseases  are  also  due  to  bacilli,  but  cannot  be 
further  referred  to  here. 

II. — Micrococci. 
(1)  Staphylococci. — These  occur  in  small  masses 
and  are  readily  stained  by  ordinary  aniline  dyes  and 


Micrococci.  531 

by  Gram's  method.  The  individual  cocci  measure 
about  1  [I  in  diameter.  The  chief  varieties  are  S. 
pyogenes  aureus,  S.  pyogenes  albus,  S.  citreus. 

(2)  Streptococci. — This  group  contains  a  con- 
siderable number  of  pathogenic  organisms.  They 
occur  in  shorter  or  longer  chains. 

{a)  S.  pyogenes. — Stains  as  the  staphylococci. 
It  produces  a  severe  suppuration  with  a  great 
tendency  to  indeterminate  extension. 

(6)  S.  erysipelatosus  is  very  closely  related  to 
the  last,  and  certainly  cannot  be  distinguished  by 
cov^er-glass  preparations  or  by  culture  methods.  The 
chains  contain  from  five  or  ten  to  as  many  as  forty 
cocci.  Many  authorities  regard  it  as  only  a  virulent 
form  of  S.  pyogenes. 

(3)  PiieumococcHs  (diplococcus  pneumoniae, 
Frsenkel) . — These  diplococci  are  the  cause  of  croupous 
pneumonia,  though  they  occur  also  in  normal  saliva. 
They  are  lancet-shaped  and  the  points  of  the  lancets 
are  directed  towards  each  other.  The  diplococcus  is 
enclosed  in  a  capsule  which  stains  less  deeply  than 
the  cocci  themselves.  Occasionally  one  capsule  con- 
tains four  cocci.  They  stain  readily,  and  are  coloured 
by  Gram's  method,  which  aids  in  distinguishing  them 
from  Fried  lander's  pneumo  -  bacillus,  as  the  latter 
cannot  be  stained  by  it.     (Frontispiece,  d.) 

(4)  Micrococcus  tetrag-eniis. — This  organism 
is  found  in  the  sputum  which  comes  from  phthisical, 
bronchiectatic  and  other  cavities  in  the  lungs.  The 
cocci  are  about  1*5  \x  in  diameter,  and  occur  in  groups 
of  four  enclosed  in  a  capsule.  They  are  readily 
coloured  by  Gram's  method  and  by  basic  aniline  dyes. 

(5)  Oonococciis. — This  is  a  diplococcus,  the  two 
cocci  of  which  lie  very  closely  together  and  are  thus 
difficult  to  distinguish.  With  high  magnification  they 
are  seen  to  be  kidney-shaped  and  have  their  concave 
sides  facing  one  another.       Sometimes  the  gonococci 


532  Clinic  A  l   Bacteriology. 

are  found  free ;  at  other  times,  and  more  character- 
istically, enclosed  in  pus  corpuscles,  in  which  they 
occur  in  groups.  They  are  readily  stained  by  aqueous 
solutions  of  basic  aniline  dyes.  They  are  decolorised 
by  Gram's  method,  which  often  aids  in  clinching  the 
diagnosis  in  a  doubtful  case.  Advantage  may  also 
be  taken  of  the  fact  to  secure  a  double  stain,  the 
cover  glass  being  first  treated  by  Gram's  method  and 
then  counterstained  with  Vesuvine  or  Bismarck 
brown.  Most  of  the  other  microbes  then  stain  violet, 
the  cellular  elements  are  light  brown,  and  gonococci 
are  darker  brown.     (Frontispiece,  e.) 

(6)  Sarciiia  ventriculi  is  described  elsewhere 
(p.  82). 

III.  — Actinomyces. 

The  ray  fungus  (Figs.  77  and  135)  has  been  placed 
in  various  groups  of  fungi  by  different  observers. 
It  has  affinities  with  several  classes,  but  is  perhaps 
best  associated  in  the  meantime  with  a  somewhat 
miscellaneous  group  under  the  heading  "  Fungi  im- 
perfecti,"  as  has  been  proposed  by  Winter.*  It 
may  be  found  in  pus,  sputum,  faeces,  urine,  or  in 
tissues  removed  by  operation  or  after  death.  It 
occurs  in  the  form  of  minute  yellow  granular  masses, 
which  are  generally  recognised  without  much  diffi- 
culty under  the  microscope.  The  most  expeditious 
method  for  its  demonstration  is  to  crush  a  small  granule 
immersed  in  a  drop  of  glycerine,  between  a  micro- 
scopic slide  and  cover  glass.  Treated  thus,  one  sees  a 
radiating  cluster  of  pear-shaped  bodies,  whilst  in  the 
centre  of  the  mass  the  filaments  of  an  interlaced 
mycelium  may  be  observed.      If  a  stained  preparation 

*  Rabenhorst.  Kryptogamenflora.  Bd.  I.  Die  Pilze,  bearb. 
von  Dr.  Georg  Winter.  The  present  tendency  is  to  regard  it  as 
more  closely  related  to  the  streptothrix  section  of  bacteria  than 
to  any  other  group. 


A  C  TINOM  YCES.  533 

is  wanted,  a  good  method  *  is  to  desiccate  a  layer  of 
pus  on  a  cover  glass,  then  to  wash  it  with  ether  and 
immerse  in  a  concentrated  solution  of  caustic  potash. 
From  this  it  is  transferred  to  a  5  per  cent,  solution  of 
eosin  in  water,  where  it  remains  for  a  quarter  of  an 
hour.  It  is  finally  washed  in  a  concentrated  solution 
of  acetate  of  potash  and  mounted  in  the  same  medium. 
The  centre  of  the  mass  is  stained  a  bright  red,  the 
clubs  pale  pink  or  yellow. 

The  mycelial  elements  are  well  stained  by  Gram's 
method,  and  thionine  blue  also  yields  satisfactory 
preparations. 

*  Lemiere  and  Bdcue. 


534 


APPENDIX. 
Weights  and  Measures. 


Eiig^lisli  weig^lits  and  measures. 

1  grain,  gr. 

1  ounce,  oz. 

=  437*5  grains. 

1  pound,  lb. 

=  16  ouiices  =  7,000  grains. 

1  minim 

=  0-91146  grain. 

1  fluid  drachm 

=  60  minims. 

1  fluid  ounce 

=  8  fluid  drachms. 

1  pint 

=  20  fluid  ounces. 

1  gallon 

=  8  pints. 

Relation  of  Eng^lisli  to  metric  system, 

1  grain 

=  64-8  milligrammes. 

1  ounce 

=  28-3  grammes. 

1  lb. 

=  453 '6  grammes. 

1  gramme 

=  15-432  grains. 

1  kilo 

=  2  lb.  3  oz. 

1  minim 

=  0-059  cc. 

1  fluid  drachm 

=  3-5  cc. 

1  fluid  ounce 

=  28-39  cc. 

1  pint 

=  567-9  cc. 

1  cc. 

=  16-9  minims. 

1  litre 

=  35-2  fluid  ounces. 

1  inch 

=  2-54  cm. 

1  foot 

=  30-48  cm. 

1  yard 

=  91-44  cm. 

1  cm. 

=  0-39  in. 

1  metre 

=  39-37  in. 

3.  Conversions. 

To  convert  grammes  per   100   cc.  into  grains  per 
ounce,  multiply  by  4-375. 


Appendix :  Temperature  Scales. 


535 


To  convert  grammes  into  ounces  avoirdupois, 
multiply  by  10  and  divide  Ly  283. 

To  convert  litres  into  pints,  multiply  by  88  and 
divide  by  50. 

To  convert  kilos  into  pounds,  multiply  by  1,000 
and  divide  by  454. 

4.  Centigrade  and  Falirenlieit  scales. 

To  convert  Fahrenheit  into  Centigrade,  subtract 
32,  multiply  the  remainder  by  5,  and  divide  the 
result  by  9. 

To  convert  Centigrade  into  Fahrenheit,  multiply 
by  9,  divide  by  5,  and  add  32. 

The  following  table  shows  the  relation  of  degrees 
Fahrenheit  to  Centigrade,  as  far  as  is  likely  to  be 
required  in  clinical  work  : — 


Centigrade. 

Falireulieit. 

Centigrade. 

Falirenheil 

110       ... 

..       230 

37        

98-6 

100       ... 

..      212 

36-5      

97-7 

95       ... 

..      203 

36         

96-8 

90       ... 

..      194 

35-5      

95-9 

85       ... 

..       185 

35         

95-0 

80      ... 

..      176 

34         

93-2 

75      ... 

..      167 

33         

91-4 

70      ... 

..      158 

32         

89-6 

65      ... 

..       149 

31         

87 -8 

60      ... 

..      140 

30         .  .       .. 

86 

55      ... 

..      131 

25         

77 

50      ... 

..      122 

20         

68 

45      ... 

..       113 

15         

59 

44      ... 

..      111-2 

10         

50 

43      ... 

..      109-4 

+    5         

41 

42      ... 

..      107-6 

0         

32 

41       ... 

..      105-8 

-    5         

23 

40-5  ... 

..      104-9 

-10         

14 

40      ... 

..      104-0 

-15         

+  5 

39-5   ... 

...       103-1 
...       102-2 

-20         

-4 

39      ... 

0-54°        ...       = 

1° 

38-5   ... 

..      101-3 

1          ...       = 

1-8 

38      ... 

..       100-4 

2         ...       = 

3-6 

37-5  ... 

99-5 

2-5        ...       = 

4-5 

53^  Clinical  Methods. 

Solutions  Required  for  Examination  of  Gastric 

Contents. 

5.  Phlorog:liicin  and  vanillin  i^olution. 

Dissolve  2  grms.  of  phloroglucin  and  1  grm. 
of  vanillin  in  30  cc.  of  absolute  alcohol.  Keep  the 
solution  in  the  dark,  and  use  it  economically,  as  the 
ingredients  are  costly. 

6.  Boas's  resorcin  reag^ent. 

Kesorcin         ...  ...  ..       75  grs. 

White  sugar  ...  ...  ...      45  grs; 

Dilute  spirit  ...  ...  ....        3|  oz. 

Dissolve. 

7.  Uffelmann's  Reag^ent. 

Carbolic  acid  (1  in  20)  ...      10  cc. 

Water ...  .  ...  ...     20  cc. 

Mix. 

Add  one  or  two  drops  of  liq.  ferri  perchlor.  An 
amethyst  blue  solution  results.  It  should  be  pre- 
pared fresh  each  time,  as  it  does  not  keep.  Lactic 
acid  turns  it  yellow.  Hydrochloric  acid  simply 
discharges  the  blue  colour.  Acetic  acid  turns  it 
somewhat  brownish. 

8.  Congo  red  test  papers. 

These  are  made  by  soaking  bibulous  paper  in  a 
solution  of  Congo  red,  of  the  strength  of  1  deci- 
gramme to  100  cc.  of  water,  or  in  a  saturated 
alcoholic  solution.  They  are  allowed  to  dry,  and  are 
then  ready  for  use. 

Solutions  Required  for  Urinary  Testing. 

9.  I^tandard  nitrate  of  silver  solntion. 

Dissolve  29-063  grms.  of  pure  y?*5ef/ silver  nitrate 
in  distilled  water,  and  till  up  to  1  litre.  Keep  in 
the  dark. 


Appendix :  Solutions.  537 

10.  Standarcl  iiraiiiiiiii  solution. 

Dissolve  35  orms.  of  uranium  nitrate  in  90  cc.  of 
water  to  which  has  been  added  .^'O  cc.  of  glacial  acetic 
acid  ;  then  fill  up  to  100  cc. 

1  cc.  =  5  mc(.   P0O-. 

11.  Acetic  solution  of  sodium  acetate. 

Dissolve  lOOgrms.  of  crystals  of  sodium  acetate  in 
some  water;  add  100  cc.  of  strong  acetic  acid,  and 
dilute  with  water  to  1  litre. 

12.  Hypobroniite  solution. 

Dissolve  100  grms.  of  caustic  soda  in  250  cc.  of 
water.  Cool,  then  add  25  cc.  of  bromine.  The 
solution  is  apt  to  undergo  the  following  decompo- 
sition : — 

3  NaBrO  =  2  NaBr  +  NaBrOg. 

It  is  therefore  better  to  prepare  it  as  required  by 
adding  2*5  cc.  of  bromine  to  25  cc.  of  the  caustic 
soda  solution. 

13.  Esbacli's  reagent. 

Dissolve  10  grms.  of  picric  acid  and  20  grms.  of 
citric  acid  in  about  900  cc.  of  boiling  water;  cool, 
and  add  water  to  1  litre. 

14.  Feliling^'s  solution. 

(a)  Take  34-64  grms.  of  pure  sulphate  of  copper 
which  has  been  powdered  and  pressed  between  bibu- 
lous paper,  dissolve  in  200  cc.  of  warm  distilled  water, 
cool,  and  fill  up  to  500  cc. 

(6)  Dissolve  180  grms.  of  crystallised  Rochelle 
salt  in  300  cc.  of  hot  water,  fi.lter,  and  add  70  grms. 
of  pure  caustic  .soda,  or  100  grms.  of  potash;  cool; 
fill  up  to  oOO  cc. 


53^  Clinical  Methods. 

When  required,  mix  equal  voluQies  of  {a)  and  (6). 
Tbe  result  is  an  alkaline  solution  of  potassic  cupric 
tartrate,  of  which  1  cc.  is  exactly  reduced  by  5  mg.  of 
pure  glucose 


15.  Pavy's  solution. 

Required — 

Cupric  sulphate 

Rochelle  salt 

... 

4*158  grms. 
(361  grs.). 
20*4  grms. 

Caustic  potash 
Strong  ammonia 

... 

(178  grs.). 
20-4  grms. 
...     300  cc. 

(Specific  gravity  0 
Water  to 

•880) 

(6  oz.). 
...      1  litre. 
(Ipt.). 

Dissolve  the  Rochelle  salt  and  potash  in  part  of 
the  water,  and  the  sulphate  of  copper  in  another 
(with  the  aid  of  heat),  pour  the  copper  solution  into 
that  of  the  alkali  and  Rochelle  salt,  cool,  add  the 
ammonia,  then  fill  up  to  1  litre  or  1  pt. 

Keeps  indefinitely.      10  cc.  =  5  mg.  glucose. 

16.  Peptone    solution     for    testing:   for    bile 

acids. 

Powdered  peptone  (Savory  and  Moore's)  \  dr. 
Salicylic  acid  ...  ...  ...  ...      4  grs. 

Acetic  acid      ...  ...  ...  ...     \  dr. 

Distilled  water  to       .  .  ...  ...     8  oz. 

Filter  repeatedly  until  transparent. 

Solutions  Required  in  the  Examination  of  Blood. 

17.  Diluting  fluid  for  liaeinocytoineter. 

Sulphate  of  soda     ...  ...      104  grs. 

Acetic  acid  ...  ...  ...  1  dr. 

Distilled  water        ...  ...  6  oz. 


18. 


Appendix:    J 

Stains 

Hsiyciii's  !»ioliitioii. 

Common  salt  ... 

1  grm. 

Sulphate  of  soda 

5  grms. 

Corrosive  sublimate  ... 

0*5  grm, 

Distilled  water 

•  •  • 

200  cc. 

539 


19.  Teicliiiiaiiii's  test  for  blood  (IisEiiiiti  test). 

Take  up  some  of  the  deposit  to  be  examined  in 
a  pipette.  Rub  it  up  with  a  small  amount  of  common 
salt,  and  evaporate  a  little  of  the  mix- 
ture to  dryness  on  a  slide.  Moisten 
the  residue    with   glacial  acetic    acid,  ^^^  ^ 

and   put   on  a   cover   o-lass.      Gently  „ 

^  n  Fjo'    137 Hcemin 

heat  this  over  a  very  small  name  for  crystals.'  Highly 
several  minutes,  avoiding  boiling,  magnified. 
Allow  a  little  glacial  acetic  acid  to  run  in  from  the 
side  of  the  cover  glass  from  time  to  time  during 
the  process.  Allow  to  cool,  and  examine  for  hfemin 
crystals  with  a  high  power  (Fig.  137). 


Some  Stainixg  Methods. 

20.  Oram's  iiietliocl. 

The  following  solutions  are  required  : — 

(1)  A  solution  of  gentian  violet  in  aniline  water. 

This  is  prepared  as  follows  : — 

Place  in  a  test  tube  1  part  of  aniline  oil  and 
20  of  ordinary  water.  Shake  these  thoroughly  to- 
gether, and  filter.  Preserve  the  filtrate  (a)  in  a 
stoppered  bottle  in  the  dark.  Prepare  a  saturated 
alcoholic  solution  of  gentian  violet  and  filter  it  (b). 
To  9  parts  of  {a)  add  1  part  of  (6)  and  filter  the 
mixture.  The  two  solutions  should  only  be  mixed 
shortly  before  use ;  after  twenty-four  hours  the  stain 
becomes  less  trustworthy. 


54<5  Clinical  Methods. 

(2)  A  solution  of  1  grai.  of  iodine,  and  2  grms.  of 
iodide  of  potash  in  300  cc.  of  distilled  water. 

Float  the  cover  slip,  face  downwards,  in  a  capsule 
containing  some  of  the  stain.  In  the  cold  the  film  is 
usually  stained  in  five  minutes ;  if  the  fluid  is  heated 
till  steam  rises,  in  about  one  minute.  Wash  the 
cover  slip  in  water,  then  place  it  for  half  to  one 
minute  in  solution  2.  Here  the  film  becomes  black. 
It  is  then  washed  in  alcohol  or  methylated  spirit 
until  it  ceases  to  lose  colour  and  becomes  a  pale  grey. 
Wash  in  water.  Dry  between  filter  papers.  Mount 
in  xylol  balsam. 

The  following  modification  of  Gram's  method  will 
be  found  simpler  and  more  efl&cient.  For  aniline 
oil  water  substitute  a  1  in  20  aqueous  solution  of 
phenol  in  the  same  proportions,  and  carry  out  the 
staining  as  detailed  above.  After  treatment  with  the 
iodine  solution,  and  washing  with  alcohol,  transfer  to 
clove  oil,  which  increases  the  sharpness  of  the  dif- 
ferentiation ;  wash  out  the  clove  oil  with  alcohol, 
then  transfer  to  water,  employ  a  contrast  stain  if 
desired,  wash  again  in  water,  dry,  and  mount  in 
xylol  balsam. 

Some  bacteria  retain  this  stain,  especially  tubercle, 
leprosy,  diphtheria,  tetanus,  and  anthrax  amongst 
bacilli ;  and  streptococci,  staphylococci,  micrococcus 
tetragenus,  and  diplococcus  pneumoniae  (Frsenkel) 
amongst  cocci ;  but  many  are  decolorised  by  the 
process,  and  are  thereby  distinguished  from  those 
already  mentioned. 

21.  Ziehl-lVeeliseii  stain. 

A.  Fuchsin,  1  part  |  dissolve 

Absolute  alcohol,  10  parts/ 
Add  of  5  per  cent,  aqueous  solution  of  phenol  100 
parts. 

B.  Twenty  per  cent,  sulphuric  acid. 


Appendix  :    Stains.  541 

C.  Watery  solution  of  methylen  blue.  The  solu- 
tion should  be  nearly  saturated.  The  addition  of  a 
trace  of  ammonia  increases  the  precision  of  the 
staining. 

Method. — Heat  A  till  steam  rises,  then  float  cover 
glasses,  film  down,  on  it  for  three  or  four  minutes, 
rinse  in  water,  immerse  in  B  till  decolorised,  wash  in 
water,  counterstain  if  desired  in  C  for  one  minute  or 
more,  wash  rapidly  in  water,  dry,  and  mount  in  xylol 
balsam  for  permanent  preparations,  or  Farrant's 
medium  if  not  to  be  preserved.  Sections  require 
longer  staining  and  must  not  be  dried  ;  clove  oil 
should  not  be  used  for  clearing  purposes,  as  it  often 
decolorises  the  bacteria. 

22.  LiOffler's    stain.       (This     should     be     freshly 

prepared.) 

Concentrated    alcoholic    solution    of 

methylen  blue    ...  ...  ...      1  cc. 

Caustic    potash    in    00 -1     per    cent. 

aqueous  solution  ...  ...      3  cc. 

Specimens  are  stained  in  from  five  to  thirty  minutes. 
Excess  of  stain  is  discharged  by  rapid  washing  in 
water  acidulated  wdth  acetic  acid  (2  drops  of  acid  in 
a  watch-glassful  of  water)  and  all  traces  of  acid  well 
washed  out.     The  specimen  is  then  dried  and  mounted. 

23.  Carbol  thionine.     (Prepared  freshly.) 

Saturated     solution    of    thionine  in 

50  per  cent,  alcohol       ...  ...        10  cc. 

1  in  40  solution  of  phenol  in  water        100  cc. 

This  stain  is  one  of  the  best  for  film  preparations. 
After  staining,  which  is  rapidly  effected,  wash  the 
specimen  in  w^ater,  then  dry  and  mount.  Sections 
should,  after  washing,  be  passed  through  alcohol 
containing  a  trace  of  ammonia,  thereafter  dehydrated 


542  Clinical  Methods. 

by  absolute  alcohol,  cleared  with  xylol,  and  mounted 
in  balsam. 

24.  Aniline  water  is  made  by  shaking  up  1 
part  of  colourless  aniline  oil  with  3  parts  of 
distilled  water  in  a  bottle  of  dark  glass.  The  excess 
of  oil  sinks  to  the  bottom,  and  the  supernatant  aniline 
water  is  decanted  and  filtered,  when  it  is  ready  for 
use.  Both  the  aniline  oil  and  the  aniline  water  must 
be  kept  in  bottles  of  dark  glass. "^ 

25.  ElirlicU's  triple  stain. — This  is  also  known 
by  the  misleading  name  of  the  "  triacid  "  mixture.  It 
contains  the  same  ingredients  as  the  Ehrlich-Biondi 
stain,  but  in  somew^hat  different  proportions.  The 
staining  ingredients  are  : — 

Orange  G. 
Acid  fuchsin. 
Methyl  green. 
These  should  always  be  obtained  from  Griibler  &  Co., 
of    Leipsic,    or  from   one   of  their   agents.      The   in- 
gredients may  be  obtained  in  the  form  of  a  powder 
(the   Ehrlich-Biondi  or  Ehrlich-Heidenhain  powder), 
which  one  can  then  make  up  into  the  stain  for  oneself 
in  the  following  portions  : — 

Powder  ...  ...  ...     gr.  xv. 

Absolute  alcohol  ...      1  cc. 

Distilled  water  ...  ...     6  cc. 

Or  one  can  make  the   stain  up  according  to  Ehrlich's 
directions,  thus  : — 

Saturated  water  solu.  of  Orange  '-'Gr"  120-135  cc. 
,,  ,,  acid   fuchsin     80-165  cc. 

„  ,,  Methyl  green  125  cc. 

(These  must  have  become   thoroughly  saturated   by 
being  allowed  to  stand  for  some  days.) 

*  It  is  now  usual  to  substitute  a  1  in  20  aqueous  solution  of 
phenol  for  aniline  water.  It  is  more  readily  prepared,  keeps 
better,  and  its  mordant  action  is  quite  as  efficient. 


A  PPENDIX :    St  A  INS.  543 

Mix  these  with  thorough  shaking  and  add,  the 
shakinsr  beine:  continued  : — 

Glycerin  ...  ...      100  cc. 

Absolute  alcohol  ...      200  cc. 

Distilled  water  .. .  ...      300  cc. 

The  mixture  once  made,  should  not  be  again  shaken, 
but  should  be  left  to  stand  for  some  time  to  "ripen  " 
and  to  allow  of  sedimentation.  When  it  is  used,  the 
supernatant  fluid  should  be  drawn  o^  by  means  of 
a  pipette. 

The  stain  having  been  made  in  either  of  the  above 
ways,  should  be  used  undiluted.  Blood  films  stain  in 
it  in  from  one  to  five  minuies,  depending  upon  the 
particular  blood  under  examination,  the  mode  of  its 
fixation,  and  also  upon  the  specimen  of  stain  used.  The 
exact  time  required  can  therefore  only  be  found  out 
by  experiment. 


IJSTDEX. 


Abdomen,  Anatomy  of,  49 

Auscultation  of,  68 

Examination  of,  51 

Inspection  of,  51 

Measurement  of,  58 

Palpation  of,  54 

Percussion  of,  57 

Regions  of,  49 

Abdominal  Muscles, Paralysis  of, 420 

Acetic  Acid,  Test  for,  79 

Acetone  in  the  Urine,  323,  324 

Albumin  in  the  Urine,  296,  297,  299 

Albumosuria,  300 

Alcaptonuria,  272 

Alimentary  System,   Questions  to 

be  asked  in  Disease  of,  6,  7 
Amblyopia,  389 
Amimia,  386 
Amnesia  Verbalis,  385 
Ansesthesia,  428 
Analgesia,  429 
Aneurysm,  Murmurs  in,  155 

Percussion  of,  123,  124 

Pulse  in,  171 

Angulus  Ludovici,  98,  214 
Aniline  Water,  542 
Anosmia,  387 
Aorta,  Site  of  Bifurcation,  51 

Situation  of,  137 

Aortic    Aneurysm,  Percussion    of, 

123,  124 

Area,  138 

Incompetence,  178 

Pulsation,  112 

Stenosis,  178 

Apex-beat,  Definition  of,  101 

Extent  of,  103,  109 

Palpation  of,  109 

• Site,  101 

Aphasia,  Definition  of,  381 
Appetite,  6 
Arcus  Senilis,  23,  453 
Ai-tery,  Middle  Cerebral,  376 

Posterior  Cerebral,  374 

• State  of  (in  examining  Pulse), 

159 

Vertebral,  374 

Articulation,  Tests  for  Power  of,  384 


Ascites,  58 

Asthma,  Signs  of,  256 

Astigmatism,  455 

Ataxy,  422 

Atheroma,  Pulse  in,  171 

Athetosis,  427 

Attitude,  16 

Auditory  Meatus,  Examination  of, 
468 

Nerve,  411 

Aura,  431 

Auscultation  in  Children,  493 

Auscultatory  Sounds,  Mode  of  Re- 
cording, 265 

Bacillus  Anthracis,  530 

Cholerae,  529 

Coli,  529 

Diplitheriae,  523 

of  Typhoid,  526 

Tuberculosis,  523 

Bacteria,  Stains  for,  514 
Bacteriology,  Clinical,  512 
Battery,  Medical,  443 
Biermer's  Phenomenon,  239 
Bile  Acids  in  Urine,  Tests  for,  321 

in  the  Urine,  319 

Pigment  inUrine,  Tests  for,  320 

Bilharzia  Hsematobium,  345 
Bilious  Stools,  86 
Bimanual  Palpation,  54 
Bladder,  Centre  for,  440 
Blebs,  Definition  of,  349 
Blepharitis,  Marginal,  451 
Blood,  Alkalinity  of,  208 
Bacteriological     Examination 

of,  519 

Coagulability  of,  208 

Density  of,  206 

Examination  of,  181,  497 

Expectoration  of,  257 

Films,  Examination  of,  202 

Fixation  of,  198 

How  Made,  197 

Staining  of,  199,  201 

Microscopic  Examination  of, 

193 
Platelets,  Estimation  of,  IBS 


Index. 


545 


Blood,  Pressure,  Gauging  of,  101 

Questions  to  be  asked  in  Afl'ec- 

tions  of,  8 

Specific  Gravity  of,  206 

Bloody  Stools,  SO 

Boas's  Resorcin  Reagent,  7S,  530 

Boils,  32 

Bone  Diseases,  Questions  Regard- 
ing, 10 

Bones,  Examination  of,  481 

of  Children,  Examination  of,     ' 

492  i 

Brachycephaly,  484  ; 

Brain,  Blo(Xl  Vessels  of,  374  I 

"Brassy  Cougli,"  35  I 

Breath,  Character  of,  46 

Sounds,  Absence  of,  243 

Graphic  Record  of,  265 

in  Children,  498 

Broca's  Convolution,  382 

Bronchial  Breathing,  242 

Bronchitis,  Acute,  252 

Chronic,  252 

Bronchophony,  246 

Broncho-vesicular  Breathing,  245 

Bruit  de  Diable,  154 

de  Galop,  141 

Bruits  Vascular,  155 

(iSee  o.lsQ  Murmurs) 

Bull«,  Definition  of,  349 

Butyric  Acid,  Test  for,  79 

Calculi,  Urinary  Analysis  of,  328 

Cauccr  Cells,  508 

Capsules  for  Bacteriological  Stain- 
ing, 513 

Carbol-thiunine  Stain,  541 

Carbonates  in  the  Urine,  336 

Carbuncles,  32 

Cardiac  Asthma,  179 

Cycle,  134 

Dulness,  118 

Diminution  of,  128 

Increase  of,  123 

Impulse  (.See  Apex-beat) 

Murmurs  (.b'ee  Murmurs) 

Sounds  (See  Heart  Sounds) 

Thrills,  110 

Valves,  Sites  of,  13(i 

Carotid  Pulsation,  105,  113 

Case-taking,  Divisions  of,  2 

Method  of,  1 

Scheme,  12 

Centigrade  aud  Fahrenheit  Scales, 
535 

Cervical  Enlargement,  365 

Cestoda,  90 

Chest,  Expansion  of,  226 

Inspection,  99 

J    J 


Chest,  Landmarks  on,  93 

Measurement,  225 

Movements  of,  220  * 

Palpation  of,  223 

Percussion  of,  229 

Regions  of,  211 

Shai)e  of,  213 

Children,  Case-taking  in  Diseases 

of,  10 

Clinical  Examination  of,  489 

Children's  Diseases,  Special  Ques- 

ti'ms  in  Cases  of,  10 
Cholera  Stools,  Examination  of,  529 

Stools  in,  86 

Cholesterin  Crystals  in  Fluids,  508 

in  Sputum,  263 

in  Uiine,  336 

Choreic  Movements,  426 
Choroid,  Tubercle  of,  467 
Circulatorv    System,    Examination 

of,  97 
Questions  to  be  Asked  in 

Disease  of,  8 
Collapse,  39 
Colour-blindness,  392 

Sense,  391 

Coma,  379 

Complexion,  27 

Conjunctiva,  Examination  of,  451 

Consonance,  250 

Constipation,  6 

Continued  Fever,  39 

Conversions,  Table  of,  534 

Convulsions,  425 

Co-ordiuation,  Tests  for,  in  Lower 

Limbs,  423 

Upper  Limbs,  423 

Cornea,  Examination  of,  452 
Cough,  8 

Causes  of,  34 

Character  of,  33 

Cover-glasses    for    Bacteriological 

Work,  514 
Cranial  Xerves,   Investigation  of, 

387 
Craniotabes,  485 
Cranium,  Diseases  Affecting,  25 
Crepitations,  Varieties  of,  249 
Crisis,  41 

Cultures,Method  of  Inoculating,  517 
Cyrtometer,  225,  226 
Cysticercus,  90 
Cystin,  326 
Cysts,  Exploration  of,  504 

"Death-rattle,"  83 
Decubitus,  16 
Defsecation,  439 
Delirium,  41,  379 


546 


Clixical  Methods. 


Delusions,  370 
Dentition,  42 
Desquamation,  350 
Diabetes,  Amount. of  Sugar  ^lassed 
in,  318 

Odour  of  Breath  in,  4(5 

Diabetic  Coma,  Urine  in,  32.5 
Diarrhoea,  (5 

Diastolic  Pulsation,  105 
Diathesis,  22 

Diazo-reaetion  in  Urine,  320 
Dicrotic  Pulse,  172 
Dicrotism,  164,  172 
Dioptre,  Definition  of,  438 
Diphtheria,  45 

BaciUus  of,  523 

Diplopia,  396,  398 
Doliclioceplialy,  484 
Dropsical  Fluids,  Characters  of,  509 
Dropsy,  Hydraimic  and  Passive,  28 

Local,  29 

Mode  of  Recognising,  29 

Dysentei'ic  Stools,  86 
Dysentery,  Amreba  of,  95 
Dysmenonhcpa,  Attitude  in,  19 
Dyspnoea,  8,  33 

Ear,  External,  Examination  of,  468 
Ears,  Appearances  of,  in  Disease,  25 
Examination  of,  in  Children, 

500 
Echoing,  Power  of,  385 
Ehrlich's  Triple  Stain,  201.  542 
Electrical  Examination  of  Muscles, 

440 

Nerves,  440 

Electrical  Reactions  of  Muscles,  448 

— Alterations  in,  448 

Electrodiaguosis,  446 
Emaciation,  22 
Emphysema,  252 

Percussion  Sound  in,  236 

Subcutaneous,  29,  351 

Emprosthotonos,  425 
Empyema,  Pulsating,  106 
Ejiigastric  Region,  49,  50 

Pulsation,  52,  106 

Palpation  of,  113 

Epigastrium  Systolic    Depressioii, 

107 
Episternal  Notch,  Pulsation  in,  105 
Equilibration,  411,  413 
Eustachian  Catheter,  Passage  of,  471 
Examinaticni,  Physical,  11 
Excoriations,  349 
Expectoration,  8 
Expiration,  Prolongation  of,  243 
Exploration,  502 
Expression,  22,  25,  26 


Exudates,  Bacteriological  Examina- 
tion of,  522 

•  Characters  of,  509 

Eye,  Abnormal  Movements  of,  400 
— —  Appearances  of,  in  Disease,  23 

Examination  of,  451,  500 

Muscles,  Examination  of,  395 

Eyebrows,  Arcliing  of,  23 
Eyelashes  in  Strumous  Subjects,  23 
Eyelids,  Eversion  of,  452 
Eyes,  Movements  of,  396 

Face,   Abnormal    INIuscular    Move- 
ments in,  411 

Facial  Expression,  23 

Nerve,  Anatomy  of,  408 

Facies  Hippocratica,  26 

Pieces,  Bacteriological  Examination 
of,  523 

Naked-eye  Examination  of,  84 

Falirenheit  and  Centigrade  Scales, 
535 

Family  History,  3 

Fauces,  Examination  of,  45 

Favus,  356 

Fehling's  Solution,  Composition  of, 
537 

■ •  Test,  310,  311,  314 

Fever,  Course  of,  41 

Types  of,  39 

Fibrinuria,  273 

Fifth  Nerve,  Anatomy  of,  405 

Motor  Root  of,  406 

Sensory  Functions  of,  407 

Filaria  Sanguinis  Hominis,  194 

Films  for  Bacterioh)gical  Examina- 
tion, 515 

Finger  Percussion,  116 

Fingers,  Changes  in  Disease,  30 

Fits,  Method  of  describing,  380 

Questions  regarding,  10 

Flags,  Use  of,  to  mark  Pulsations, 

107 
•Flatulence,  6 

Fluids  Obtained  by  Puncture,  Phy- 
sical Examination  of,  504 

Pathological   Examination  of, 

502 

Foetal  Heart  Sounds,  58 

Fontanelle,  Anterior,  491 

Forceps  for  Holding  Slides,  514 

Fourth  Nerve,  393 

Fremissement  Hydatique,  57 

Fremitus,  Vocal,  227 

Friedreich's  Phenomenon,  239 

Gait,  20 

Studv  of,  485 

Types,  486,  487,  4SS 


JNDEX. 


547 


Gall-bladder,  Examination  of,  OS 

Galvanometer,  445 

Gastric  Analysis,  70 

Contents,  Acidity  of,  77 

Gerhardt's  Phenomenon,  239 

Giddiness  in  Heart  Disease,  S 

Girth,  how  Measured,  21 

Relation     to      Height       and 

Weight,  21 

Glasses,  How  to  Tell  the  Refrac- 
tion of,  450 

Glucose  in  the  Urine,  30S 

Glycuronic  Acid  in  Urine,  325 

Gmelin's  Test,  320 

Gram's  Method  of  Staining,  539 

Grip,  Strength  of,  29 

Gums,  Examination  of,  43 

Gynecological  Examination,  0,  7 

Habits,  Questions  Regarding,  4 

HEematoma  Auris,  25 

Hsematoporphyrin  in  Urine,  306 

Htemin  Test,  539 

Ha;mocytometer,  181,  185.  189 

Diluting  Fluid  for,  53S 

Haemoglobin,  Estimation  of,  181 

Hfemoglobinometer,  192 

Hsemoglobinuria,  306 

Hgemometer,  Von  FleischVs,  189 

Hallucinations,  379 

Hands,  Examination  of,  29 

Health,  Questions  Regarding,  4 

Hearing,  Tests  for,  412 

Heart,  Anatomy  of,  97 

Aiiscultation  of,  132,  497 

Borders  of,  119,  121 

Dilatation  of,  126 

Diminished  Dulness,  128 

Diseases,  Symptoms  of,  178 

Displacements  of,  130 

Graphic  Record  of  Outline  of, 

264 

Increased  Dulness,  123 

- —  Outline  of,  264 

Percussion  of,  117,  120 

Sounds,  138,  139,  140,  141,  142 

Hectic  Flush,  25 

Height  and  Weight,  Relation  be- 
tween, 21 

Hemianeesthesia,  428 

Hemianopsia,  391 

Hemichorea,  426 

Hemiplegia,  422 

Herpes  Labialis,  24 

Hiccough,  35 

Hippoeratic  Facies,  26 

Hippocratic  Succussion,  252 

Hippus,  405 

History,  Family,  3 


History,  Personal,  4 
"Hot  Sponge"  Test,  483 
Hutchinson's  Teeth,  43 
Hydatid  Fluid,  Composition  of,  93 

Thrill,  57,  92 

Hydrocephalus,  484 
Hydropericardium,   Dull    Area  in, 

124,  127 
Hyperacusis,  413 
Hyperpesthesia,  428 
Hyperalgesia,  429 
Hyperpyrexia,  38 
Hypochondrial  Regions,  49,  50 
Hypodermic  Syringe,  Sterilisable, 

513 
Hypogastiic  Region,  49,  50 
Hysterical  Cough,  35 

Idiopathic  Heart  Diseases,  179 

Iliac  Regions,  49,  50 

Image,  Ophthalmoscopic,  461 

Immersion  Lens,  Use  of,  516 

Indigogens  in  Urine,  298,  322 

Induction  Coil,  445 

Inferior  Vena  Cava,  Obstruction  of, 
53 

Inflammatoiy  Effusions,  Characters 
of,  509 

Influenza  Bacillus,  523 

luoculation  of  Tubes,  517 

Intelligence  in  Children,  Estima- 
tion of,  500 

Intermittent  Fever,  39 

Internal  Capsule,  360 

Interossei,  Paralysis  of,  418 

Interrogation  of  Patient,  2,  3,  5 

Intestines,  Examination  of,  74 

Percussion  of,  57,  74 

Questions    to     be    Asked    in 

Disease  of,  7 

Iris,  Diseases  and  Movements  of,  24 

Itch,  353 

Jaundice,  7,  27,  347 
Jaw  Jerk,  438 

Joint  Diseases,  Questions  Regard- 
ing, 10 
Joints,  Examination  of,  481 

Kiflney,  Diagnosis,  from  Gall- 
bladder and  Spleen,  73 

Floating,  73 

■ Movable,  73 

Palpation  of,  72 

Kidneys,  Anatomy  of,  72 

Examination  of,  72 

Questions  to  be  asked  in  Dis- 
ease of,  9 

Knee  Clonus,  438 


i48 


Clinical  Methods. 


Knee  Jerk,  435,  436,  500 
Kyphosis,  219,  483 

Lactic  Acid,  Test  f(ir,  78 

Lactose  in  Urine,  31S 

Lalling,  380 

Laryngoscopj'',  472 

Larynx,  Movements  of,  32 

Nerve  Supply  of,  415,  416 

Leading  Questions,  when  Permis- 
sible, 3 

Left-handedness,  Detection  of,  378 

Lenses,  458 

Leucin  as  a  Urinary  Deposit,  334 

r>eucocytes.  Enumeration  of,  186 

in  the  Urine,  338 

Varieties  of,  202 

Leucocythfemia,  187,  203 

Leucocytosis,  188 

Leucomata,  452 

Leucorrhoea,  7 

Lips,  Appearances  of,  in  Disease,  24 

Examination  of,  42 

Lipuria,  339 

Liver,  Anatomy  of,  64 

■  Diminution  of,  68 

Displacement  of,  68 

Enlargement  of,  68 

Examination  of,  64 

Expansile  Pulsation  of,  113 

in  Children,  497 

■  Inspection  of,  65 

Palpation  of,  65 

Percussion  of,  Q'o 

•  Pulsation  of,  ^*6 

Questions  to  be  asked  in  Dis- 
ease of,  7 

Lobar  Pneumonia,  Physical  Signs 
of,  254 

Locomotory  System,  481 

Liiffler's  Bacillus,  523 

Stain,  541 

Lordosis,  483 

Lumbar  Enlargement,  365 

•  Puncture,  503,  510 

Eegions,  49,  50 

Lungs,  Anatomy  of,  209 

Apices  of  (Percussion),  231 

Auscultation  of,  240,  498 

Bulging  of  Apices,  32 

Percussion,  231,  232 

•  Questions  to  be  asked  in  Dis- 
ease of,  S 

Resonance,  236,  237 

Lymphadenoma,  Leucocytes  in,  203 

Lymphatic  Glands,  31 

Lysis,  41 

Macular  Region,  Characters  of,  463 


Macule.  Definition  of,  348 
Main  en  Griffe,  30,  419 
Malaria,  Parasite  of,  201 
Malta  Fever,  528 
Mammary  Line,  99 

Region,  212 

Melansemia,  194 

Memory,  Investigation  of,  379 

Menstruation,  6 

Micturition,  9,  439 

Middle  Ear,  Inflation  of,  471 

Milk-Sugar  in  Urine,  318 

Mind-blindness,  386 

Mineral  Acids,  Test  for,  78 

Mitral  Area,  138 

Disease,  Pulse  in,  170 

■  Incompetence,  178 

Murmurs,  144 

Stenosis,  178 

Monoi^legia,  422 
Motor  Area,  358 

Functions,  Investigation  of,418 

— -  Path,  Anatomy  and  Physiology 

of,  358 

Points,  446 

Mouth,  Examination  of,  42,  494 
Movable  Kidney,  73 
Mucinuria,  302 
Murmurs,  Aortic,  14S,  149 

Cardiac,  142,  143,  144 

-Due  to  Malformations  of  Heart, 

152 

Graphic  Record  of,  264 

Hsemic,  153 

Mitral,  145,  147 

Multiple,  151 

Presystolic,  145 

Pulmonary,  150 

Tricuspid,  149 

Vascular,  155 

Muscles,  Nutrition  of,  424 

Tone  of,  364,  434 

Muscular  Sense,  365,  430 

Nails,  Changes  in  Disease,  30 

Nebulte.  452 

Neck,  Diseased  Conditions  in,  31 

Pulsation  in,  112 

Rigidity  of,  32 

Root  of.  Pulsation  at,  112 

Nematoda,  87 
Neoplasms,  Abdominal,  60 
Nervous  Case,  Order  of  Examina- 
tion of  a,  377 

Diseases,  Attitudes  in,  19 

System,  358 

Questions  in  Disease  of,  9 

Nose,  Appearances  of,  in  Disease,  24 
Examination  of,  477 


Index. 


549 


Nucleoalbumiiiuiin,  302 
Nutrition,  20 
Nystagmus,  401 

(Edema,  Detection  of,  3ol 

Localised,  29 

(Esophagus,  Anatomy  of,  47 

Auscultation  of,  4S 

Examination  of,  47 

Oil  Immersion  Lens,  Use  of,  516 

Olfactory  Nerve,  387 

Ophthalmic  Division  of  Fifth  Nerve, 

405 
Ophthalmoscope,  456 
Ophthalmoscopv,  Direct,  460 

in  Children,  500 

Indirect,  457 

Opisthotonos,  425 
Optic  Atrophy,  466 

Disc,  Characters  of,  462 

Fibres,  Course  of,  387 

Nerve,  387,  388 

Neuritis,  464 

•  Radiation,  388 

Orthopnoea,  18 

Osteal  Percussion  Sounds,  114 

Ovarian  Tumours,  60 

Pain  a  Cause  of  Special  Attitude,  17 

Expressions  in,  26 

in  Abdomen,  6,  7 

Sensibility  to,  429 

Palate,  Examination  of,  45 

Hard,  484 

Innervation  of,  415 

Reflex,  432 

Soft,  Innervation  of,  415 

Pallor,  27 

Palpitation,  8 

Pantomime,  Power  of  Interpreting, 

386 
Papillitis,  464 
Papule,  Definition  of,  349 
Parsesthesia,  431 
Paragraphia,  386 
Paralysis,  10,  422,  499 
Paralysis  Agitans,  Attitude  in,  19 
Paramimia,  386 
Parai^hasia,  385 
Paraplegia,  422 
Paresis,  422 
Parosmia,  387 
PaiTOt's  Nodes,  492 
Pathological  Fluids,  511 
Pavey's  Solution,  538 
Pectoriloquy,  246 
Pediculosis,  353 
Pentosuria,  318 
Pepsin,  Test  for,  79 


Peptone  in  tlie  Urine,  302 

Solution,  538 

Percussion,  113,  116,  117,  493 

Finger,  116 

Flicking,  57 

Pericardial  Effusion,  124,  127,  140 

Friction,  156 

Thrills,  111 

Pericarditis,  179 

Dull  Area  in,  124,  127 

Sounds  in,  156 

Pericardium,  Puncture  of,  503 
Perigraph,  226 
Perihepatitis,  '^^ 
Peristalsis,  Visible,  53 
Peritoneal  Cavity,  Puncture  of,  503 
Peritonitis,  Attitude  in,  18 
Pertussis,  34,  35 
Pettenkofer's  Test,  321 
Pharynx,  Examination  of,  45,  495 
Phonendoscope,  133 
Phosphates,  Crystals  of,  334 

in  the  Urine,  276,  281 

Phtliisis,  Physical  Signs  of,  253 

Pitceon  Breast,  217 

Plessor,  116 

Pleural  Cavity,  Puncture  of,  503 

Friction,  250 

Sacs,  Line  of  Reflection  of,  210 

Thrills,  111 

Pleurisy,  Physical  Signs  of,  255 
Pleurosthotonos,  425 
Pleximeter,  116 
Pneumonia,     Chronic    Interstitial, 

Physical  Signs  of,  254 
Pneumo    -    pericardium.         Heart 
Sounds  in,  140 

Pneumothorax,  Heart  Sounds  in, 141 
Phvsical  Signs  of,  255 

Prsecordia,  98,  100,  101 

Palpation  of,  108 

Precordial  Distress,  8 

Pulsation,  104,  111 

Pressure,  Sense  of,  429 

Proteids  in  Urine,  296 

Pruritus,  431 

Pulmonary  Area,  138 

Artery,  Pulsation  Over,  111 

Cavity,    a    Cause    of   Special 

Attitude,  17 

Pulsation,  Diastolic.  105 

Pulse,  Amplitude  of,  160 

Blood  Pressure  in,  161 

Dicrotlsm  of,  164,  172 

Examination  of,  157 

Force  of,  159 

in  Children,  490 

Rate  of,  158 

Rhvthm  of,  159 


550 


Clinical  Methods. 


Pulse,  Tension  of,  lt32 

Tidal  Wave,  164 

Tracings,  Characters  of,  165 

Varieties  of,  159,  170,  171,  172, 

173,  174 

Venous,  175 

Pupil,  Abnormal  Movements  of,  405 

Argyll-Robertson,  405 

Reflexes,  432 

Use  of  Mydriatics  for  Dilata- 
tion of,  459 

Pupils,  Examination  of,  401,  402 

Mobility  of,  24 

Reaction  of,  to  Accommoda- 
tion, 404 

Purulent  Stools,  86 

Pus,  Bacteriological  Examination 
of,  522 

Expectoration  of,  257 

in  the  Urine,  305,  822,  338 

Pustule,  Definition  of,  349 

Pyrexia,  39 

Pyuria,  322 

Quadriurates  in  Urine,  276 

Quartan  Fever,  40 

Quotidian  Intermittent  Fever,  40 

Rales,  Classitt  cation  of,  248 

Rectal  Examination,  75 

Rectum,  Centre  for,  440 

Red  Blood  Corpuscles,  Nucleated, 
203 

• Number  of,  185 

Reflex  Functions  of  Nervous  Sys- 
tem, 431,  434,  439 

Regurgitation  in  Veins,  175 

Relapsing  Fever,  Spirillum  of,  530 

Remittent  Fever,  39 

Renal  Arteries,  Site  of,  51 

Calculus,  Attitude  in,  19 

Colic,  Attitude  in,  19 

Resonance,  ^Egophonic,  248 

Amphoric,  239,  247 

Boxy,  238 

Cracked-pot,  238 

Emptying  of,  114 

Factors  in,  230 

Full,  114 

Muttled,  115 

■ of  Lung,  114 

Percussion,  113 

Skodaic,  236 

-—  Tympanitic,  114 

Vocal,  245 

Respiration,  Characters  of,  in  Dis- 
ease, 32 

Cheyne-Stokes,  221 

Forms  of  Obstructed,  32 


Respiration  in  Cliildren,  490 

Movements  in,  220 

Rate  of,  221 

Rattling,  33 

Rhythm  of,  221 

Type  of,  222 

Respiratory     Diseases,    Symptoms 

of,  252 

Excursion,  244 

System,    Examination    (jf,    in 

Children,  498 
Retinal  Haemorrhages,  467 
Retinoscopy,  454 
Rheumatic  Nodules,  492 
Rhinoscopy,  477,  478 
Rhonchi,  Varieties  of,  248 
"  Rice-water  "  Stools,  86 
Rickets,  Skull  in,  484 
Rigor,  38 
Ringworm,  354 

Sarcina  Ventriculi,  82 

Scabies,  353 

Scabs,  350 

Scapula,  Position  of,  211 

Scoliosis,  483 

Serobiculus  Cordis,  214 

Segmental  Functions  of  Cord,  Table 
of,  366 

Sensibility  to  Pain,  429 

Sensory  Functions,  Investigation 
of,  427 

Path,  Anatomy  and  Physiology 

of,  364 

Seventh  Nei-ve,  408 

Sibili,  248 

Sighing  Respiration,  33 

Sight,  Centres  for,  388 

Sixth  Nerve,  393 

Skin,  Colour  of,  347 

Diseases,  Questions  Regard- 
ing, 9 

Elasticity  of,  351 

Eruptions,  28,  348 

Examination  of,  27,  347 

Microscopic  Examination,  353 

Palpation  of,  351 

Skull,  Bossing  of,  492 

Examination  of,  483 

Measurement  of,  483 

Palpation  of,  484 

Shape  of,  484,  491 

Sleep,  379 

Slides,  Cleaning  of,  197 

for  Bacteriological  Work,  514 

Smell,  Tests  for,  387 

"Smoky  Urine,"  304 

Snellen's  Types,  389 

Spasm,  424 


Index. 


551 


Spectra,  Chart  of,  207 
Speech  Centres,  382 

Investigation  of,  380 

Sphygmograph,  Use  of,  165 

Sphygmometer,  161 

Spinal  Accessory  Xerve,  414,  416 

Cnnl,  Anatomy  of,  365 

Blood  Supply  of,  377 

Tracts  of,  369 

Spleen,  Anatomy  of,  6;' 

Auscultation  over,  72 

Enlargement  of,  72,  497 

Inspection  of,  69 

Palpation  of,  70 

• •  Percussion  of,  71 

Splenic  Infarcts,  72 

Sputum,  S,  257,  258,  259 

Bacteriological      Examination 

of,  518 

Crystals  in,  261 

Examinaion  of,  256 

Fibrin  Casts  in,  260 

Parasites  in,  263 

Squint,  395 

Stains  for  Blood,  2f)l 

for  Bacteria,  514 

Stammering,  380 

Sternum,    Sounding-board     Action 

of,  118 
Stethoscopes,  Varieties  of,  132 
Stomach,  Absorptive  Power,  SO 

Auscultation  of,  (54 

Chemical  Examination,  76 

Contents,  Acidity  of,  77 

Analysis  of,  76 

Dilated,  63 

Dislocated,  63 

Inflation  of,  61 

Insi^ection  of,  61 

Motor  Power,  80 

Palpation  of,  61 

Percussion  of,  62 

Tube,  Method  of  Passing,  47 

Stools,  Character  of,  in  Infants,  497 

Strabismus,  395 

Sugar,  Detection  of,  in  Pathological 

Fluids,  506 

•  in  the  Urine,  307,  314 

Sulphates  in  the  Urine,  283 
Superficial  Reflexes  in  Children,  500 
Symbols,  Use  of,  2 
Syphilis,  4 

Congenital,  Skull  in,  484 

Swabs  for  Bacteriological  Work,  512 
Swallowing,  Auscultation  of,  48 

Tape  Worms,  90 
Taste,  Nerves  of,  407 
Tests  for,  408 


Teeth,  Examination  of,  43,  494 
Temperament,  22 
Temperature,  3t),  37,  3S 

in  Children,  Taking  the,  492 

Sense,  429 

Tendon  Reflexes,  434 
Tertian  Fever,  40 
Test  Meal,  76 
Tetany,  425 

Thermometer,  Use  of,  36 
Third  Nerve,  393 
Thorax    (.See  Cliest) 
Thrills,  Cardiac,  110 

in  Bloodvessels,  113 

in  Carotids   113 

Pericardial,  111 

Pleural,  111 

Thread  Worm,  87 

Throat,  Examination  of,  472,  494 

Exanunation  of,  for  Diphtheria 

Bacillus,  524 
Thrush,  44 
Thyroid  Gland,  31 
Tinnitus,  413 
Tongue,  Examination  of,  44,  494 

Mobility  of,  417 

Tonsils,  Examination  of,  45 

Tophi,  25 

Torticollis,  31 

Torula,  82 

Touch,  Centre  for,  365 

How  to  Test  Sense  of,  428 

Trachea,  Bifurcation  of,  210 
Tracheal  Tugging,  112 
Transudates,  Characters  of,  509 
Traube's  Space,  63 
Trematoda,  93 
Tremor,  426 
Tricuspid  Area,  138 
Trommers  Test,  309 
Trophic  Changes  in  Hand,  29 
Tubercle  Bacillus,  518,  521,  523 
Tubercular  Sputum,  Bacteriological 

Exan; illation  of,  518 
Tubes,  Inoculation  of,  517 
Tumour,  Definition  of,  349 
Tuning-fork  Test,  412 
Tympanic  Membrane,  468 
Tympanitic  Percussion  Sound,  237 
Tympanic  Resonance,  114 
Typhoid,  Bacillus  of,  52o 

Fades,  27 

Fever,  Urine  in,  327 

Tyrosin  as  a  Urinary  Deposit,  333 

Utfelmann's  Reagent,  78,  536 
Umbilical  Region,  49,  50 
Umbilicus,  51,  54,  56 
Unemia,  Odour  of  Breath  in,  46 


552 


Clinical  Methods. 


Urate  of  Ammonia  as  a  Urinary 
Deposit,  335 

of  Soda,  Crystals  of,  330 

Urates,  276 

Amorphous,  in  Urinary  De- 
posits, 331 

Urea,  Detection  of,  in  Pathological 
Fluids,  507 

Estimation  of,  286 

Ureometers,  Forms  of,  287 

Uric  Acid  as  a  Urinary  Deposit,  277 

Conditions     Favouring 

Separation  of,  291 

Microscopical  Chara(;ters, 

329 

Salts  of,  291 

Test  for,  292 

Urinary  Calculi,  Analysis  of,  328 

Deposits,  Microscopical  Ex- 
amination of,  329 

Naked  Eye  Characters  of, 

275 

Indigogens,  322 

Passages,  Questions  iu  Disease 

of,  9 

Urine,  267 

Abnormal  Constituents,  296 

Bacteriological     Examination 

of,  520 

■ — -  Blood  in,  304 

Chlorides  in,  279 

Collection  of  Samples  of,  267 

Colour  of,  269,  271,  272 

• Consistence  of,  273 

"  Day  "  and  "  Night,"  268 

Density  of,  274 

■ Deposits  in,  275 

Diazo-reaction  in,  326 

Diminution  of,  269 

Drugs  in,  327 

Filtration  of,  297 

Incontinence  of,  439,  440 

Milkiness  of,  271 

■ Mucus  in,  275 

Nitrogenous   Constituents  of, 

285 

■ Odour  of,  273 

• Opalescence  of,  272 

Oxalates  in,  284 

Pallor  of,  271 

Pellicle  on  Surface  of,  273 

• Phosphates  in,  281 

• Physical  Examination  of,  267 

Quantity  of,  267,  268,  269 

Questions  Regarding,  0 

Reaction  of,  278 


Urine,  Retention  of,  439 

Specific  Gravity  of,  274 

Sugars  in,  307 

Sulphates  in,  283 

Xanthin  Bases  in,  294 

Urinonietei-,  Method  of  Using,  274 
Urobilin,  Spectrum  of,  in  Urine, 
270 

Vagus,  414 

Valve  Areas,  137,  138 

Valves  of  Heart,  Situation  of,  136 

Vascular  Bruits,  155 

Veins,  Distension  of,  on  Surface  of 

Chest,  108 
Venereal  Disease,  4 
Venous  Pulsation,  105 

Pulse,  175 

Regurgitation,  175 

Undulation,  175 

Vertebral  Column,  Examination  of, 

482 
Vertigo,  413 

Vesicle,  Definition  of,  349 
Vesicular  Breathing,  241 
Visual  Centres,  388 
Vocal  Fremitus,  227 

Resonance  in  Children,  498 

Observation  of,  245 

Voice,  Characters  in  Disease,  36 
Vomit,  Examination  of,  81 

Microscopic  Examination  of,  82 

Vegetable  Parasites  iu,  82 

Vomiting,  6 

Watery  Stools,  86 
Weight,  Sense  of,  430 
Weights  and  Measures,  Table  of,  534 
Wernicke's    Hemiopic    Pupil    Re- 
action, 403 
Whooping  Cough,  34,  35 
Widal's  Typhoid  Test,  526 
Wintrich's  Phenomenon,  239 
Word-deafness,  384 
Wright's  Coagulometer,  208 
Wrist  Drop,  419 
Wrist  Jerk,  438 
Writing,  Power  of,  385 

Xanthin  as  a  Urinary  Deposit,  333 

Yeast  Fungi,  82 
Yellowness  of  Skin,  27 

Ziehl-Neelsen  Method  of  Staining, 
540 


PniSTED  BY  CASSELL  &  COMPASY,  LIMITED,  LA  BKLIiE  SAUVAGE.  LOSDOX,  E.G. 


0 


Date  Due 

Tf/w    2 '3 

U 

i  ; 

-  .      1           ■  *.    ■ 

\\\^ 

1  A  1949 

JU»^ 

1.    J^ 

f) 

^^7' 


^3y 


